HISTORY AND PHYSICAL EXAMINATION HISTORY IDENTIFICATION: Male who initially appeared…

HISTORY AND PHYSICAL EXAMINATION HISTORY IDENTIFICATION: Male who initially appeared in the ER. Informant is patient who seems reliable and hospital records obtained. CC: Bilateral pedal edema. HPI: Patient appeared in ER complaining of bilateral pedal edema that was getting increasingly worse. Patient states he has a prior history of heart failure and recently discontinued all of his medications on his own. He denies any chest pain or shortness of breath. Denies any upper respiratory symptoms or cough. Patient stated that he lives alone and would be willing to be hospitalized to get the edema under control. His edema does have him concerned. Patient was admitted for inpatient hospitalization. PAST MEDICAL HISTORY: Medications: As stated above, patient is presently on no medications. According to medical records he has been on Levothyroxine 0.05 mg q am. Lasix 40 mg po q d, Peri-Colace 1 tablet bid and Darvocet 1-2 tablets po prn q 6 hours. ALLERGIES: No known medical allergies. PAST SURGICAL HISTORY: Bilateral hernia repair done approximately 20 years ago, gall bladder removal 1965, skin graft left leg in 12/2000. TRANSFUSIONS: Patient feels he has been transfused before but cannot recall when. CHRONIC ILLNESSES: CHF, hypothyroidism, cirrhosis of liver, osteomyelitis, PVD, COPD, ETOH abuse. FAMILY HISTORY: Father with CHF. Search