Was asked to see Mr.

History Of Present Illness

Past Medical History

Past Surgical History

Family History
Negative for premature CAD, CHF, PPM, or sudden cardiac death

Social History
Never a smoker. Denies alcohol or drug use.


no fever, no chills, no cold sweats, no weakness, no fatigue, no decreased activity.
Ear/Nose/Mouth/Throat: No decreased hearing, No ear pain, No nasal congestion, No sore throat.
Respiratory: no shortness of breath, No cough, No sputum production, No hemoptysis, No wheezing, No
Cardiovascular: No chest pain, no palpitations, no peripheral edema, No syncope.
Gastrointestinal: No nausea, No vomiting, No diarrhea, No constipation, No heartburn, No abdominal pain.
Genitourinary: No dysuria, No hematuria, No change in urine stream, No urethral discharge, No lesions.
Hematology/Lymphatics: No bruising tendency, No bleeding tendency, No petechiae, No swollen lymph
Endocrine: No excessive thirst, No polyuria, No cold intolerance, No heat intolerance, No excessive hunger.
Integumentary: No rash, No pruritus, No abrasions.
Neurologic: Alert and oriented x2. Decreased motor function LUE and LLE
Psychiatric: No anxiety, No depression, No mania.  

Physical Exam
Vital Signs

General: cachectic, lethargic but arousable, non verbal. Dry mucosa
Neck: Trachea midline, no masses.
No carotid bruit, JVP non elevated <3 cm H2O. Carotid upstrokes
preserved 2+ bilaterally
Respiratory: normal chest wall expansion, normal B/S bilaterally. No wheezes or rhonchi. No rales
Cardiovascular: RRR S1 S2 distinctly audible, no extra heart sound, no rubs. No murmur.
Abdomen: Obese, Soft, non-tender, non-distended, normal bowel sounds in all quadrants, No
hepatomegaly, no ascites, no abdominal bruit or thrill, no renal bruit.
Rectal: deferred
Musculoskeletal: normal ROM in upper and lower extremities.
Dorsalis Pedis pulses 2+ bilaterally
Integumentary: warm, dry, and pink, with no rash, purpura, or petechia
Heme/Lymph: no lymphadenopathy, no bruises. RLE amputated,
LLE no edema
Neurological: 2+ patellar reflexes, Cranial Nerves II-XII grossly intact, no tics, normal sensation to pressure
and light touch
Psychiatric: cooperative with normal mood, affect, and cognition  

Medications Active

Home Medications






Thank you for this consult. I will continue following with you through this hospitalization. Please do not
hesitate to contact me with any questions.