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HISTORY AND PHYSICAL EXAMINATION

Patient Name: Patrick Platt

Hospital No.: 771033

Room No.: 560

Date of Admission: 08/30/2008

Admitting Physician: William Payne, MD

Admitting Diagnosis: Possible fracture of left arm.

CHIEF COMPLAINT: Pain and swelling, left upper arm.

HISTORY OF PRESENT ILLNESS: The patient is an elderly mail who fell 4 days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He was presented to the emergency room for treatment.

PAST HISTORY: Past illnesses include whooping cough as a child. Tonsillectomy in 1947. No known allergies to medication.

FAMILY HISTORY: No hereditary disorders noted. Mother and father are deceased. Two brothers are alive and well. One sister has adult set diabetes mellitus

SOCIAL HISTORY: The patient is married and has 2 children. His wife does not work outside the home.

PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress, with pain and swelling in the upper left arm. Vital sign: Blood pressure 140/90, temperature 98.3, pulse 97, and respiration 18.

HEENT: Head normal, no lesions, Eyes, arcos senile, both eyes. Ears, impacted ceriman, left ear. Nose, clear. Mouth, dentures fit well, no lesions.

NECK: Normal range of motion in all directions.

(Continued)

HISTORY AND PHYSICAL EXAMINATION
Patient Name: Patrick Platt
Hospital No.: 771033
Date of Admission: 08/30/2008
Page 2

INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mL in diameter.

CHEST: Clear breathing, sounds bilateral. No riles or rhonchi noted.

HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted.

ABDOMEN: Normal bowel sounds. Liver, Kidneys, and Spleen are normal to palpitation.

GENITALIA: Testes normal descend bilaterally.

RECTAL: Prostate 2+ and benign.

EXTREMITIES: Pain and...
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