CHIEF COMPLAINT: Pain
HISTORY OF PRESENT ILLNESS:
Site -
Onset -
Character -
Radiation -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Nausea - , Vomiting - , SOB - , Sweating -
Cold exposure - , Recent trauma -
Similar pain before -
Pain typical of his sickle cell crisis -
Last crisis -
PND - , DOE - , Palpitations -
Fever/chills - , Cough - , Ankle swelling -
Muscle aches -
Claudication - , Headache - , Blackouts -
Blurred vision - , Sore throat -
Abdominal pain - , Black/bloody stool - , Difficulty walking -
Dysuria -
ER treatment given -
PAST MEDICAL HISTORY (positives are circled):
Sickle cell disease
Stroke Seizures PUD PVD DVT COPD Asthma Gallstones HTN DM
Pneumonia UTI
EGD Colonoscopy
PAST SURGICAL HISTORY (positives are circled):
Cholecystectomy Hernia GSW
MEDICATIONS:
ALLERGY: NKDA
FMH (positives are circled):
CAD<55 yo DM Stroke HTN CA SOCIAL HISTORY (positives are circled): Alcohol - heavy occasional last drink Smoker: Illicit drugs - cocaine heroin marijuana REVIEW OF SYSTEMS: unremarkable for 12/14 systems apart from the symptoms above. PHYSICAL EXAMINATION: VITAL SIGNS: SpO2 - GENERAL APPEARANCE: WD/WN in NAD SKIN: no rash HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis NECK: Supple, no JVD LUNGS: CTA (B) HEART: Clear S1S2, RRR ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: no edema PERIPHERAL VASCULAR: palpable NEURO: AAO x 3 CN 2-12: non focal MUSCLE STRENGHT: 5/5 (B) DTR: ++DTR SENSATION: non focal CEREBELLAR: non focal LABS:
Reticulocytes -
UA -
CXR:
ECG:
ASSESSMENT:
- Pain due to
Sickle cell crisis
PLAN:
- IVF
- O2 to keep SpO2 > 92%
- UA
- Urine toxic screen
- CBCD, BMP in AM
- Home medications
- Heparin 5000 U SQ BID
Signature:
Related reading:
Sickle Cell Anemia Centenary: the article "Peculiar elongated and sickle-shaped red blood corpuscles" published in 1910 http://goo.gl/SAg54
Published: 2//11/2005
Updated: 03/08/2012
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