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8/21/93 MIA (Medical Intern Admission Note?)
Informant: Patient
CC (Chief Complaint) - I fell
HPI (History of Present Illness) - This is the first CPMC (Columbia Presbyterian Medical Center)
admission for this 23 year old recent college graduate with psychiatric history significant for
Panic attacks + the suggestion of recent Depression started on Elavil 2 weeks ago.
The patient whose psychiatric care is managed by his father began to take Amitriptyline
2 weeks ago. The patient was in his USOGH (Usual State of Good Health) until 2 days PTA
(Prior to Admission) when he noticed symptoms of orthostatic hypotension. He never lost
balance or consciousness. On the morning of admission he arose early (3AM) and was not
feeling himself. He also experienced a small panic attack. While alone with his 10 year old
sister this morning, the patient fell from a standing position and began to write like a fish out
of water according to the girl. The LOC (Loss of Consciousness) lasted 10 (minutes) and was
not associated with fecal or urinary incontinence. The patient was confused by the time EMS
arrived but A&OX3 (Alert and Oriented) upon arrival in the E.R.
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The patient denies drug abuse, O/D (Over Dose) attempt, suicidal or homicidal ideation - he
had a normal EEG 1 - years ago.
Past Medical History Crohn's Disease - now in remission, bloody stools from 16 - 19 with +
(positive) colonoscopy
PSH x negative (?)
Allergies ?Immodium
PE (Physical Examination) 160/80, P(ulse) 110, R(espirations) 16 (lying down)
170/90, P(ulse) 110 (Standing)
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PE (Physical Examination continued)
Well developed WN (Well Nourished) young man looking his stated age, lying nervously in his
stretcher in the ER, he had hypotension but talked clearly
the head erythematous contusions covered with Vaseline diffusely across the face.
HEENT (Head, Ears, Eyes, Nose, Throat) - Pupils ERRLA (Equal and Reactive to Light),
neck supple, negative nodes, negative JVD (Jugular Venous Distension).
Lungs - CTA (Clear to Auscultation)
CV - RR n/s1s2 (?)
Abd(omen) + BS (Bowel Sounds), - HSM(?) SNTND(?)
Ext(ernal) +pulses Equal
Neuro (Neurological Examination): A&OX3 (alert and oriented)
nonfocal (?) exam
CXR (Chest X-ray)
ECT ST 100-110 (?heart rate), PR (PR interval) .16/.11 QRS widening
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