CHIEF COMPLAINT: SOB x ......... hours/days/months
HISTORY OF PRESENT ILLNESS:
Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Nausea - , Vomiting - , SOB - , Sweating - , Chest pain -
Similar SOB before -
Previous ABx therapy -
Sick contacts -
Last HD - HD access -
Making urine -
PND -, Orthopnea -, DOE -
Heart racing -
Fever/chills - , Cough -, Ankle swelling -
Claudication - , Headache - , Blackouts -
Blurred vision - , Sore throat - , Nasal discharge -
Lightheaded - , Dizzy -
Leg/calf pain - , Recent travel -
Abdominal pain - , Black/bloody stool -
Dysuria- PPD- Flu shot this year-
ER Tx given -
PAST MEDICAL HISTORY: (circle all that apply)
ESRD on HD -
Where - When -
Nephrologist -
Access - AVF AV graft HD catheter
MI CAD HTN DM COPD Asthma Pneumonia Prior intubations-
CHF
Catheterization -
2D-Echo -
Stroke CA PUD PVD DVT Gallstones
EGD Colonoscopy
PAST SURGICAL HISTORY: (circle all that apply)
CABG Cholecystectomy Hernia GSW Hysterectomy
MEDICATIONS:
ALLERGY: NKDA
FMH: (circle all that apply)
CAD DM Stroke HTN CA
SOCIAL HISTORY: (circle all that apply)
Independent NH Lives w spouse son daughter
Alcohol - no heavy occasional last drink
Smoker: no
Illicit drugs - no cocaine heroin marijuana
REVIEW OF SYSTEMS: unremarkable apart from the above symptoms
PHYSICAL EXAM:
PHYSICAL EXAM:
VITALS: Orthostatics -
SpO2 - Initial vitals -
GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD +JVD
LUNGS: CTA (B) crackles L R B wheezing
HEART: Clear S1S2, RRR irregular murmur S D /6 S3
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema +edema HD access-
PERIPHERAL VASCULAR: palpable nonpalpable Doppler
NEURO:
AAO x 3, CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B), SENSATION: nonfocal
DTR: ++, CEREBELLAR: non focal
LABS:
N= B=AG= LFT
Blood Cx:
Urine Cx: UA: Sputum Cx:
ABG:
CXR:
EKG:
Cardiac enzymes x 1 - negative , BNpep
ASSESSMENT:
- If infection - BCx x 2, CXR, Vancomycin 1 gm IV x 1 + Gentamycin 80 mg IV x 1
- If AV fistula clotted - venogram, Vascular surgeon consult
PLAN:
- HD
- CBCD, BMP in AM
- Cardiac enzymes x 1 more, 8 hr after the 1st one
- EKG now and in AM
- O2 to keep SpO2 higher than 92%
- Tylenol 650 mg PO q 4-6 hr PRN pain or fever
- Home meds - check list and restart accordingly
- Heparin 5000 U SQ BID
Signature:
Published: 02/12/2005
Updated: 03/08/2009
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