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Chief Complaint:

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

Vital Signs:

Blood Pressure:

117 / 72 mm Hg

Heart Rate:

87 BPM

Height: 

66 inches

Weight

159 lbs

Respiratory Rate:

15 /min

Temperature:

99.6 degrees F

Allergies:

NKDA

Social Hx:

Smoking History - Prior history of smoking, quit 2 years ago. Smoked 3 packs per day.

Alcohol Use - Social alcohol intake only

Illicit Drugs - Prior IVDA, quit 4 years ago. Denies needle sharing.

Marital Status - Married

Physical Exam:

General: Mildly dyspneic, skin pallor and diaphoretic.

HEENT: Tympanic membranes congested, clear discharge.

Chest: 1+ rales, dull to 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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