GoldenDelicious said:
i dont ring up sales i just count the money

and make sure all the corpses of the patients on the floor are disposed of properly
1) Upon gross examination of the patient, he appears to a mildly obese young male in his late twenties. His chest and neck was ausculated showing no signs of bruit or murmurs. JVD is negative, neurologic is negative for remarkabitity. Outward appearance is remarkable for lack of clothing style.
2) His blood pressure is elevated at 150/95. Patient admits to freely abusing alcohol leaving to concomittant raise in basal bp. Patient refuses to consider lifestyle changes. Its recommended 40mg of furosemide per day to alleviate the fluid buildup.
3) LA is upper limits of normal, mitral valve is normal with mild to moderate leakage secondary to his enlarged left atrium.
4) LV is mildly enlarged and concentric hypodynamic contraction is observed secondary to questionable alcoholic cardiomyopathy. The LV outer dimensions are thickened, questionable as to hypertrophic due to alcohol induced hypertension or alcohol induce hypertrophic cardiomyopathy.
5) The aortic valve is normal and trileaflet with normal excursion. There is no sign of aortic stenosis or aortic regurgitation.
6) The inferior vena cava is distended at 3.1cm with no inspiratory collapse, the RA is grossly enlarged in comparison with the LA. The tricuspid valves is normal with mild~mod amount of tricuspid regurgitation. The tricuspid regurgitant gradient is elevated at 42mmHg of mercury suggesting mild~mod pulmonary hypertension.
7) The right ventricle is normal in systolic motion and in gross dimensions. The RVFW is however upper limits of normal @ subjectively 8mm showing questionable increased afterload of pulmonary pressures..
8) THere is no obvious pericardial effusion.
These finding are consistent with a selfinvolved alcoholic of late twenties. His PA pressures are indeed elevated suggestive of a backup of alcohol induced hypertension secondary to a moderate mitral regurgitation. This at this point should not be viewed as a surgical need as proper behavior modification can be made to negate open heart valve replacement.
The subject is also at risk of poor prognosis of open heart surgery due to health and lifestyle and at this point, the surgery is not approved.