Pt. name:  Dale Mayman                        Admitting Physician:   Dr. S Phillips       
Age: 51                                           DOB: 11/13/xx                             Bed: ER Bed 2
Admitting diagnosis: Confusion bleeding gums
Pt. ID # 542768                                                Med Rec #:  78543
Wt. lbs: 172  kg: 78                 Ht.: 71 inches                                 Race:Caucasian
Major Support:  Wife                                                                      Religion:Not stated

Immunizations: current
Allergies: Ace inhibitors (angioedema)

History and Physical

Patient: Carson, Sarah
Age: 65
Birthdate: 01/20/1948
Admitting Diagnosis: Non-small cell carcinoma, right lung, recurrent

History:  Patient was diagnosed with non-small cell carcinoma of the right lung in 2010.  Diagnosis confirmed by CT scanning, needle biopsy, and frozen pathology specimen during right lower lobectomy in May of 2010.  Subsequent treatment includes directed radiation therapy and two rounds of chemotherapy.  Patient developed multiple adverse side effects to the chemotherapy agent and treatment was discontinued.  Diagnosis was amended to recurrent carcinoma of the right lung with metastases to both lungs and positive lymph nodes throughout chest in June of 2013.  Diagnosis confirmed by CT scanning.  Patient elected to discontinue all aggressive treatment and was brought on home hospice service six weeks ago.  History of COPD, mild CHF, and osteoarthritis noted.  Patient has NKDA with exception of reactions to chemotherapy agent.  Patient has denied pain and takes Acetaminophen for occasional headaches or joint discomfort.

Physical:
Height: 64cm
Weight: 52.2kg
Vital Signs: HR 79bpm, regular rhythm; RR 22bpm, non-labored; T 37.2; B/P 130/76; O2 saturation 93% on room air.
Lungs: Diminished in right base, otherwise clear to auscultation.
Heart: Appropriate HR and regular rhythm.  S1,S2 without murmurs, rubs, gallops.
Musculoskeletal: Joint swelling and tenderness without joint deformity.  Slight generalized muscle weakness.
Genitourinary: Voids without difficulty or pain.  Bowel sounds normoactive in all quadrants.  No abdominal masses or tenderness.