CHIEF COMPLAINT: Nausea / Vomiting x ........ hours/days/months
HISTORY OF PRESENT ILLNESS:
Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Similar symptoms before -
Nausea -
Vomiting -
Diarrhea -
Loss of appetite -
Black/bloody stools -
Abdominal pain -
Recent antibiotic use - , Recent travel -
Sick contacts - , Suspicious food consumed -
Fever/chills - , SOB - , Cough - , Chest pain - , Headache -
Dizzy - , Passed out - , Sore throat -
Muscle aches - , Back pain -
Dysuria -
ER Tx given -
PAST MEDICAL HISTORY: (circle all that apply)
PUD Gallstones Kidney stones UTIs MI CAD HTN DM
Stroke CA PVD DVT COPD Asthma
EGD -
Colonoscopy -
PAST SURGICAL HISTORY: (circle all that apply)
Cholecystectomy Hernia Appendectomy 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 symtpoms
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
Rectal exam:
EXTREMITIES: no edema +edema
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= L=
Amylase Lipase , Anion gap= , LFT
Cardiac enzymes x 1 - negative
CXR:
KUB:
EKG:
ASSESSMENT:
- N/V due to
*Gastroenteritis
*Gastritis
*PUD
*Pancreatitis
*Cholecystitis
*Diverticulitis
*UTI
PLAN:
- NPO apart from meds
- IVF
- Stool WBC, O/P, C/S, Stool C.diff
- Urine C+S
- CBCD, BMP in AM
- Liver/gallbladder U/S
- GI consult
- Phenergan 12.5 mg IV q 4 hr PRN N/V
Or
- Zofran (ondansetron) PRN
- DVT prophylaxis
Signature:
Published: 02/12/2005
Updated: 03/08/2009
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