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Page history last edited by camorales@... 2 years, 7 months ago

Things in Bold must be included.  ROS and PE have areas where you can pick which options you would like to include or leave out.  

 

Medicine History and Physical

 

PCP:

 

Contact Person:

 

Code Status:

 

Chief Complaint:

 

HPI:

4 HPI elements (Location, quality, severity, duration, timing, modifying factors, and associated signs and symptoms) or the status of 3 chronic or inactive problems.

 

ROS: (Need 10 systems with at least 1 bullet, you pick)

The patient currently denies

(Constitutional) fever chills,

(Eyes) changes in vision, blurry vision,

(ENT) changes in hearing, runny nose, sore throat,

(Cardiovascular) CP, palpitations, lower extremity swelling,

(Respiratory) SOB, cough, wheezing,

(Gastrointestinal) nausea, vomiting, constipation, diarrhea,

(Genitourinary) feelings of dysuria or changes in urination,

(Musculoskeletal) muscle or joint pain, change in range of motion,

(Integumentary) new rashes or changes in skin,

(Neuro) HA, dizziness, numbness, tingling, confusion

(Psych) changes in mood, feelings, or depression,

(Endocrine) changes in weight, feelings of cold/heat intolerance, polyuria/polydipsia

(Heme/Lymph) easy bruising/bleeding, swollen lymph nodes

(Allergic/Immune) frequent infections, seasonal allergies

 

Past Medical History:

Piror Illness or injuries

Prior Operations

Prior Hospitalizations

 

Allergies:

 

Past Family History:

Health status/Cause of Death of Parents, Siblings, Children

Specific Diseases related to the problem related to the Chief Complaint

Disease of family members (DMII, MI, HTN, Cancer)

 

Social History:

Marital Status/Living arrangements

Current Employment

Alcohol Use

Tobacco Use

Drug Use

 

Current Outpatient Medications Reviewed:

Active Inpatient Medications

 

Physical Exam: (Need 2 bullets from 9 systems, you pick)

Vitals: Temp, HR, BP, RR, O2 Sat

General- alert, pleasant, in no acute distress

Eyes – Eyes atraumatic and conjunctiva are non-injected and w/o icterus

Ears Nose, Throat- Ears atraumatic, nose without discharge or erythema, oropharynx without erythema or exudate, unremarkable dentition, gums appear intact and without blood

Lymphatic- no anterior cervical, posterior cervical, or Axillae/upper extremity lymphadenopathy appreciated

Respiratory- symmetric chest movement with respirations, air movement appreciated throughout all lung fields, clear to auscultation bilaterally, no use of accessory muscles, no wheezes or crackles

Cardiovascular- regular rate and rhythm, no murmurs, no LE pitting edema appreciated bilaterally, 2+ pedal pulses

GI- abdomen soft, non-distended, bowel sounds present, no pain to deep palpation, no hernias noted

Genitourinary – External Genitalia without lesions, no masses, bladder without fullness, no vaginal/penile discharge

Musculoskeletal- Inspection (Head, Neck, Spine, Ribs, Pelvis, Bilateral Upper and Lower Extremities) without misalignment, asymmetry, tenderness or effusions. No changes of range of motion (Head, Neck, Spine, Ribs, Pelvis, Bilateral Upper and Lower Extremities).

Skin- Overall warm and dry, no lesions, rashes or ulcers

Neuro- CN II-XII intact upon inspection, DTRs intact, proprioception intact bilaterally in upper and lower extremities

Psych- Alert and oriented to person, place, time and situation. Mood good with congruent affect.

 

Labs:

CBC, Chem 10, LFTs, CBGs, other relevant labs

 

Micro Cultures:

Blood Cultures date of collection (_/_/_):

Body Fluid Cultures date of collection (_/_/_):

 

Radiology/Imaging:

Radiologist Impression of CXR:

Radiologist Impression of CT:

Radiologist Impression of MRI:

Cardiologist Impression of TTE:

Gastroenterologist Impression of EGD/Colonoscopy:

 

Assessment / Plan by Problem (Need at least 4 Complex Problems): (Some Examples)

Ex:

- COPD Exacerbation due to PNA/allergies/medication non-compliance: Patient with home O2 requirement of _L. Patient with most recent PFTs on _/_/_.

* Contine albuterol-ipratropium nebulizations _ scheduled/PRN Q4

* Contine abx _ (start _/_/_ to _/_/_)

* Contine to titrate O2 to sats >90%

 

- Acute on Chronic Decompensated/Compensated Chronic HFrEF (_ EF, TTE _/_/_) (acute decompensated systolic heart failure): Due to ischemic cardiomyopathy/nonischemic cardiomyopathy. Weight on admission of _ (_/_/_). Cr on admission of _ (_/_/_).

* Fluid Balance in past 24 hrs of +/- _ ml

* Continue Furosemide _mg Q_

* Continue to monitor

 

- Compenstated Chronic/Acute on Chronic Decompensated Cirrhosis due to EtOH/Hep C (dx _/_/_):

* Continue Lactulose _ gm and titrate to 4-5 BMs per day

* Continue to monitor

 

- Controlled/Uncontrolled Diabetes Type II: HbA1c _ (_/_/_). CBG within last 24 hours with range of _ - _ and _ units of correctional insulin used.

* Continue Glargine _ units at bedtime

* Continue _ units Nutritional TID

* Continue Correctional scale

* Continue to monitor POC glucose

- UTI: Probable E. coli

* Contine abx _ (start _/_/_ to _/_/_)

* F/U urine cultures collected on (_/_/_)

 

 

Hospital Issues:

DVT Prophylaxis: _

Foley/Lines/Restraints: _

Code Status: _

Contact Person/Number: _

Ambulation status: _walks independently, needs assistance, use device, sits in the bed, bedridden and immobile

 

Discharge Planning:

Likely DC in _ (1-2 days, 3-5 days, >5 days)

Likely Destination: _

Follow-up Appts:

 

 

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