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PHYSICAL EXAMINATION: Vital Signs:
On arrival to the floor, blood pressure 154/84 systolic ranging from 136
to 154 and diastolic ranging from 68 to 84, temperature of 97.4, pulse 92, and
respiratory rate of 16. Intake was 340
and output was 0 mL. General: The patient is alert, responsive, and in no
acute distress and lying in bed.
HEENT: Pupils are equally round
and reactive to light with no pallor and no icterus. Neck:
Supple. No lymphadenopathy. CVS:
No JVD. S1 and S2 normal. 2/6 pansystolic murmur heard best at the
mitral area. Pulmonary: Clear to auscultation bilaterally. No chest wall tenderness. Gastrointestinal: Soft, nondistended, and nontender. Bowel sound is present in all 4
quadrants. Neurological: The patient is alert and oriented x3. GCS is 15/15.
Extremities: 1+ pulses bilaterally
with 1+ edema bilaterally in the lower legs.
INVESTIGATIONS:
Sodium 138, potassium 4.8, chloride 94, bicarbonate 29, BUN 58,
creatinine 9.8, glucose 166, GFR of 7, calcium 9.5, and albumin 3.1. VBG done in the ECA shows pH of 7.43, pCO2 of
47, CPK 122, CK-MB 1.7, myoglobin 243, troponin 0.07, BNP 3,233. Hemoglobin 8.7. hematocrit 28, WBC 5.2,
platelet 181, and MCV 89.9. EKG shows
sinus rhythm with 1st degree AV block with frequent PVC.
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