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Chief Complaint:

42 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

Vital Signs:

Blood Pressure:

168 / 87 mm Hg

Heart Rate:

100 BPM

Height: 

66 inches

Weight

153 lbs

Respiratory Rate:

12 /min

Temperature:

98.9 degrees F

Allergies:

ALLERGEN: Latex --> REACTION: Wheezing, Rash
ALLERGEN: Shellfish --> REACTION: Anaphylaxis
ALLERGEN: Peanuts --> REACTION: Trouble breathing

Social Hx:

Smoking History - Current Smoker, 1 packs per day.

Alcohol Use - Social alcohol intake only

Illicit Drugs - Prior IVDA, quit 1 years ago. Denies needle sharing.

Marital Status - Widowed

Physical Exam:

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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500 Avenue of Americas, New York, NY 10024

Tel: 123-456-7890

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