HISTORY AND PHYSICAL EXAMINATION

Name: Samuel Lowell

ID#: 11345 Room: 3307
Physician: Shawn Lipinski, MD
Admitted: 04/25/2012
Date of Birth: 06/05/1972
HISTORY OF PRESENT ILLNESS
Mr. Lowell is a 40-year-old male admitted to Columbia River General Hospital for
treatment of deep vein thrombophlebitis in his left lower extremity. He was tre
ated for this without incident and seemed to improve. Between that episode and t
his, he had an episode of pain in his left flank area, which was evaluated in th
e Columbia River General Hospital Emergency Room with laboratory studies, includ
ing an intravenous pyelogram. About one week ago, he was trying to get back into
shape and started working out on a treadmill. He noted some discomfort in his l
eft calf, which he attributed to muscle pain and continued his exercise. Over th
e past 24 hours, the left lower extremity has become more painful and swollen. D
r. Melina at the North Shore Medical Clinic saw him and an ultrasound was perfor
med demonstrating clear evidence for deep venous thrombosis. He is now admitted
for treatment of that condition. He has not have an undue shortness of breath no
r has he had any palpitations, cough, or chest pain.
CONSULTATION
Dr. Melina requested a consultation by Dr. St. Claire, a physician at North Shor
e Medical Center, who confirmed the diagnosis of deep venous thrombosis.
PAST MEDICAL HISTORY
Mr. Lowell has had the usual childhood diseases without rheumatic or scarlet fev
er, yellow jaundice, pneumonia, or kidney infections. He has had no previous sur
gery. He does not smoke and never has. He drinks alcohol only rarely. He current
ly is taking aspirin for pain but no other medications. He has no drug allergies
.
FAMILY HISTORY
Mother and father are living and well, as are his siblings. Several aunts have h
ad cancer, one of these being breast cancer. There is no family history of coagu
lation disorders.
PHYSICAL EXAMINATION
Mr. Lowell is a well-developed male, who appears somewhat older than his stated
age.
VITAL SIGNS
Blood pressure was 140/80 and the pulse rate was 100.
HEENT
The jugular venous pressure was normal. The neck was supple with no thyromegaly.
LUNGS
The lungs were clear.
HEART
The heart was not demonstrably enlarged. The first sound was single; the second
sound was normally split.
ABDOMEN
The abdomen was obese, without hepatosplenomegaly. The bowel sounds were normal.
EXTREMITIES
Edema was present in the left lower extremity below the mid-thigh. The periphera
l pulses were normal.
NEUROLOGIC
Neurologic assessment was normal.
DIAGNOSIS
Patient is diagnosed with deep vein thrombophlebitis in the left lower extremity
and tachycardia. This patient will be admitted. A pulmonary ventilation perfu
sion scan is mandated by the presence of tachycardia. A baseline study needs to
be completed to eliminate the presence of plembolization. He will be treated w
ith bed rest and anticoagulation. Further notation will be made as the case pro

gresses. Appropriate studies for coagulopathy were performed.

________________________________
_
Shawn Lipinski, MD
SL:SN
Date: July 29, 2014
Time: 5:50:03 PM