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ADMITTING DIAGNOSIS
Rule out fracture of left arm.
CHIEF COMPLAINT
Pain and swelling, left upper arm.
PAST HISTORY
Past illness includes whooping cough as a child. Tonsillectomy in the past.
No known allergies to medications.
FAMILY HISTORY
No hereditary disorders noted. Mother and father are deceased. Two
brothers are alive and well. One sister has adult-onset diabetes mellitus.
SOCIAL HISTORY
The patient is married and has 2 children. His wife does not work outside the
home.
PHYSICAL EXAMINATION
VITAL SIGNS:
Blood pressure: 140/90
Temperature: 98.3 degrees Fahrenheit
Pulse: 97
Respirations: 18.
HEENT
Head: Normal, no lesions.
Eyes: Arcus senilis, both eyes.
Patient Name: Patrick Platt
Patient ID: 771033
Date of Admission: 08/30/2018
NECK
Normal range of motion in all directions.
CHEST
Clear breath sounds bilaterally. No rales or rhonchi noted.
HEART
Normal sinus rhythm. No friction rubs noted.
ABDOMEN
Normal bowel sounds. Liver, kidneys, and spleen are normal to palpation.
GENITALIA
Testes normally descended bilaterally.
EXTREMITIES
Pain and swelling noted above the left elbow, other upper extremities
normal. No cyanosis or clubbing.
PROGNOSIS
Good.
_________________________
Marion Simpkins, MD, Orthopedics
MP: BT
D: 08/30/2018
T: 09/01/2018