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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:

155 / 66 mm Hg

心拍数:

102 BPM

高さ: 

66 inches

重さ

154 lbs

呼吸数:

10 /min

温度:

98.0 degrees F

アレルギー:

NKDA

ソーシャル Hx:

Smoking History - Current Smoker, 3 packs per day.

Alcohol Use - Social alcohol intake only

Illicit Drugs - Prior drug use, non-IVDA, quit 3 years ago.

Marital Status - Widowed

身体検査:

General: Patient comfortably seated, slightly diaphoretic.

HEENT: Tympanic membranes congested, clear discharge.

Chest: Clear to auscultation and percussion.

Abdomen: Diffuse periumbilical discomfort, no masses.

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

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