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.
Click here for image
Click here for previous page
	     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)
Click here for image
Click here for previous page
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
Click here for image
Click here for previous page
Click here for next page
Click here for beginning of chart