CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Similar sx before-
Fever- ,Chills- , Sweating-
Persistent- , Intermittent-
Sick contacts- , Travel- , Pets-
Immunizations-
Runny nose- , Sore throat- , Red eyes-
Cough- , SOB- , Wheezing- , CP-
Nausea- , Vomiting- , Diarrhea- , Blood/mucus in stools-
Skin rash- , Ext.pain/swelling-
PND- , DOE- , Palpitations-
Cough- , Ankle swelling-
Claudication- , Headache- , Blackouts-
Recent tavel-
Blurred vision- , Sore throat-
Abdominal pain-
Dysuria-
Tx given-
PAST MEDICAL HISTORY:
MI CAD Catheterization Echo CHF HTN DM COPD
Stroke CA Liver Thyroid Seizures CRI ESRD on HD
PPD-
EGD Colonoscopy
PAST SURGICAL HISTORY:
CABG Cholecystectomy Hernia GSW Hysterectomy C-section
MEDICATIONS:
ALLERGY: NKDA
FMH:
CAD<> 55 yo DM Stroke HTN CA
SOCIAL HISTORY: Independent NH Lives w spouse son daughter
Alcohol:
Smoker:
Illicit drugs:
REVIEW OF SYSTEMS: unremarkable apart from the symptoms above
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= AG= LFT
Blood Cx:
Urine Cx: , UA: , Sputum Cx:
Previous Cx:
Creatinine clearance=
ABG:
CPP x 1 - negative BNpep
CXR:
XR:
CT
EKG:
A R A R E P Q R S T
D R I I E E
ASSESSMENT:
-Septic shock-> source:
*Pneumonia
*UTI
*Intraabdominal
*Decubitus
Risk for:
Pseudomonas- previous ABx Tx Structural lung dz Nosocomial infection
MRSA- Hospital stay
-SOB due to
*Pneumonia
Previous ABx Tx-
Structural lung disease-
CAP severity score (PORT score):
-Aerosols UD q 4 hr, Robitussin
-UA
-CBCD, BMP in AM
-CPP x 1 more, 8 hr after the 1st one
-EKG now and in AM
-Tylenol 650 mg PO q 4-6 hr PRN pain or fever
-Protonix 40 mg IV QD
-Heparin 5000 U SQ BID
Signature:
----------------------
Related:
Sepsis order set. Happy Hospitalist, 08/2008.
Published: 2/11/2005
Updated: 08/11/2008
No comments:
Post a Comment