Admission Note for SOB, CHF

DATE: ...............

CHIEF COMPLAINT: SOB x  ..... days

HISTORY OF PRESENT ILLNESS:

Onset -
Character -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -
Nausea - , Vomiting - , SOB - , Sweating - , CP -
Similar SOB before -

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 -

Noncompliance with meds - , diet - , fluids -

ER Tx given -
Urine output in ER -

PAST MEDICAL HISTORY:
MI CAD CABG HTN CHF EF DM Hyperchol. Dilated CMP Pacemaker
Stroke Arrhythmias

Stress test -
2D-Echo -
Catheterization -
When - Where -

CA PUD PVD DVT COPD Asthma Gallstones EGD Colonoscopy

PAST SURGICAL HISTORY:
CABG Valve surgery
Cholecystectomy Hernia GSW Hysterectomy C-section

MEDICATIONS:

ALLERGY: NKDA

FMH:
CAD DM Stroke HTN CA

SOCIAL HISTORY:
 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:
VITALS:
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
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= , L= , B= , INR- , AG= , LFT
Cardiac enzymes x 1 - , Mg++ , TSH
BNpep - , UA: , Lipids: LDL HDL
Old CXR:
CXR:
Old EKG:
EKG on admission:

A R A R E P Q R S T
D R I I E E


ASSESSMENT:
- SOB due to
*CHF exacerbation due to
uncontrolled HTN
R/O ischemia
Noncompliance
URTI

*Bronchitis
*R/O cardiac ischemia
*Pneumonia

PLAN:
- CPP x 1 more, 8 hr after the 1st one
- EKG in AM
- ASA
- O2 to keep SpO2 > 92%
- Lasix 40 mg IV BID
- Aerosols UD q 4 hr
- UA
- Urine toxic screen
- 2D Echo
- CBCD, BMP in AM
- Fasting lipids
- Tylenol 650 mg PO q 4-6 hr PRN pain
- Home meds
- Heparin 5000 U SQ BID

Signature:


Published: 02/11/2005
Updated: 03/08/2008