The following is a transcript from my medical files from October 1, 2025 in the ER. Names have been edited out or redacted. Formatting is altered as well, but not the content other than the names. PHYSICIAN ASSESSMENT: · History: 58-year-old male Presenting to the emergency department with primary concerns of general weakness. The patient is feeling dizzy, diaphoretic, and generally weak starting today. States the last time that he ate was yesterday. Has been having some nausea, but no vomiting. Denies any fevers or chills. No chest pain or shortness for breath. Denies any abdominal pain. No recent changes to bowel or bladder function. Has been taking his medications as prescribed. No history of diabetes. It is not on any insulin or other diabetic medications. EMS found a patient with a glucose of 2.1. Was given 250 cc of D5W. Normal saline bolus also started Past medical history: Hypertension, chronic back pain, fibromyalgia, arthritis, heart failure. The patient is on Entresto. ...
Comments
Post a Comment