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主な苦情:

41 year old male patient presents to clinic with complaint of stroke/CVA and chest pain. Patient also complains of a sore throat.

Clinical Trial ELIGIBLE

バイタルサイン:

血圧:

109 / 74 mm Hg

心拍数:

77 BPM

高さ: 

66 inches

重さ

151 lbs

呼吸数:

13 /min

温度:

98.6 degrees F

アレルギー:

ALLERGEN: Codeine --> REACTION: Rash
ALLERGEN: Penicillin --> REACTION: Hives
ALLERGEN: Latex --> REACTION: Wheezing, Rash

ソーシャル Hx:

Smoking History - Prior history of smoking, quit 4 years ago. Smoked 1 packs per day.

Alcohol Use - Social alcohol intake only

Illicit Drugs - Prior IVDA, quit 6 years ago. Denies needle sharing.

Marital Status - Single

身体検査:

General: Patient comfortably seated, slightly diaphoretic.

HEENT: Mild conjunctival injection.

Chest: 1+ rales, dull to percussion.

Abdomen: Soft, no guarding, borborygmi WNL.

Extremities: Poor capillary refill, RLE 1+ DP, faint PT.

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