CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:
Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Nausea- , Vomiting- , SOB- , Sweating-
Similar CP before-
ER Tx given-
PND- , DOE- , Palpitations-
Fever/chills- , Cough- , Ankle swelling-
Claudication- , Headache- , Blackouts-
Recent tavel-
Blurred vision- , Sore throat-
Abdominal pain- , Black/bloody stool-
Dysuria-
PAST MEDICAL HISTORY (positives are circled):
MI CAD Catheterization HTN Echo Liver Thyroid Renal Epilepsy DM
Stroke CA
EGD Colonoscopy
PAST SURGICAL HISTORY (positives are circled):
CABG Cholecystectomy Hernia GSW Hysterectomy
MEDICATIONS:
ALLERGY: NKDA
FMH (positives are circled):
CAD<> 55 yo DM Stroke HTN CA
SOCIAL HISTORY:
Alcohol: Independent NH Lives w spouse son daughter
Smoker:
Illicit drugs:
REVIEW OF SYSTEMS (positives are circled):
General-> Fever Fatigue Wt loss Night sweats
Resp-> Cough Sputum Atopy Sinus sx Abnormal CXR Night sweats, PPD
Dyspnea Wheezing Job hx CP Hoarseness Exposure, travel Smoking
Cardiology-> Palpitations Orthopnea PND Swollen ankles DOE Dizzy
Orthostatic sx CP Claudication
CAD Risk factors-> HTN Obesity PVD LDL FMH DM HDL Smoking Age
GI-> Jaundice Urine color Mouth ulcers Pain Pruritus Appetite changes
Indigestion N / V / D / C Rectal blood Exposure, travel, sick contacts
Changed bowel habits Tattoos Dysphagia
GU-> Dribling Incontinence Stream weak Straining Impaired emptying
Frequency/ Urgency Nocturia Dysuria Blood in UA, color change UTIs
Stones STDs
Endocrine-> Change in Wt Urine/ Thirst/ Hunger/ Fatigue FMH: DM, Thyroid
Alopecia Tremor Temp.intolerance
Hematology-> Bruises Infections/ Glands/ Blood transfusion/donation
Bone Pain Anemia Rash Sensation changes
Rheumatology-> Limited ROM Deformity Time variation Stiffness
Tenderness Edema Fatigue Warm Erythema Locking Pain
Neuro-> Weakness Walking problems Coordination problems Paralysis
Room spinning Dizzy Memory problems Strokes Headache Incontinence
Numbness Tremors Seizures HOH Vision problems Speech problems
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
CPP x 1- negative , Mg++ TSH
BNpep- UA: Lipids: LDL HDL
ABG:
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:
-
PLAN:
-
Signature:
Created: 2/2005
Updated: 03/08/2007
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