Admission Notes: Hematology/Oncology

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

Hematology/Oncology

Admission Note for Sickle Cell Crisis

References

Hematology and Oncology Cases

Published: 01/06/2004
Updated: 09/04/2009

Recommended Books

Admission Note for Sickle Cell Crisis

DATE:

CHIEF COMPLAINT: Pain

HISTORY OF PRESENT ILLNESS:

Site -
Onset -
Character -
Radiation -
Alleviating factors -
Time course -
Exacerbating factors -
Severity -

Nausea - , Vomiting - , SOB - , Sweating -
Cold exposure - , Recent trauma -
Similar pain before -
Pain typical of his sickle cell crisis -
Last crisis -

PND - , DOE - , Palpitations -
Fever/chills - , Cough - , Ankle swelling -
Muscle aches -
Claudication - , Headache - , Blackouts -
Blurred vision - , Sore throat -
Abdominal pain - , Black/bloody stool - , Difficulty walking -
Dysuria -

ER treatment given -

PAST MEDICAL HISTORY (positives are circled):
Sickle cell disease
Stroke Seizures PUD PVD DVT COPD Asthma Gallstones HTN DM
Pneumonia UTI

EGD Colonoscopy

PAST SURGICAL HISTORY (positives are circled):
Cholecystectomy Hernia GSW

MEDICATIONS:

ALLERGY: NKDA

FMH (positives are circled):
CAD<55 yo DM Stroke HTN CA SOCIAL HISTORY (positives are circled): Alcohol - heavy occasional last drink Smoker: Illicit drugs - cocaine heroin marijuana REVIEW OF SYSTEMS: unremarkable for 12/14 systems apart from the symptoms above. PHYSICAL EXAMINATION: VITAL SIGNS: SpO2 - GENERAL APPEARANCE: WD/WN in NAD SKIN: no rash HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis NECK: Supple, no JVD LUNGS: CTA (B) HEART: Clear S1S2, RRR ABDOMEN: Soft, NT, ND, +BS EXTREMITIES: no edema PERIPHERAL VASCULAR: palpable NEURO: AAO x 3 CN 2-12: non focal MUSCLE STRENGHT: 5/5 (B) DTR: ++DTR SENSATION: non focal CEREBELLAR: non focal LABS:
Reticulocytes -
UA -
CXR:
ECG:

ASSESSMENT:

- Pain due to
Sickle cell crisis

PLAN:

- IVF
- O2 to keep SpO2 > 92%
- UA
- Urine toxic screen
- CBCD, BMP in AM
- Home medications
- Heparin 5000 U SQ BID

Signature:

Related reading:

Sickle Cell Anemia Centenary: the article "Peculiar elongated and sickle-shaped red blood corpuscles" published in 1910 http://goo.gl/SAg54

Published: 2//11/2005
Updated: 03/08/2012

Admission Note for Leg Pain

DATE:

CHIEF COMPLAINT: Leg pain x

HISTORY OF PRESENT ILLNESS:

Site-
Onset-
Character-
Radiation-
Alleviating factors-
Time course-
Exacerbating factors-
Severity-
Nausea- , Vomiting- , SOB- , CP- , Sweating-
Recent injury-
Similar leg pain before-

ER Tx given-

Cough- , Fever/chills- , Skin rash- , Swelling- , Back pain-
Headache- , Vision problems- , Sore throat-
Abdominal pain- , Black/bloody stools- , Dysuria-

PAST MEDICAL HISTORY:
MI CAD HTN DM Low back pain DVT Cellulitis Gout
Catheterization Echo
Stroke CA PUD PVD COPD Asthma Gallstones

EGD Colonoscopy

PAST SURGICAL HISTORY:
Knee surgery Cholecystectomy Hernia GSW Hysterectomy

MEDICATIONS:

ALLERGY: NKDA

FMH:
CAD<> 55 yo 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 above symptoms

PHYSICAL EXAM:

VITALS:
SpO2-

GENERAL APPEARANCE: WD/WN in NAD
SKIN: no rash
HEENT: NC/AT, PERRLA (B), moist MM, no epistaxis
NECK: Supple, no JVD
LUNGS: CTA (B)
HEART: Clear S1S2, RRR
ABDOMEN: Soft, NT, ND, +BS
EXTREMITIES: no edema
PERIPHERAL VASCULAR: palpable
NEURO:
AAO x 3
CN 2-12: non focal
MUSCLE STRENGHT: 5/5 (B)
DTR: ++DTR
SENSATION: non focal
CEREBELLAR: non focal

LABS:

N= B= L=
Blood Cx:
Urine Cx: UA: Sputum Cx:
Creatinine clearance=
XR:
CXR:

ASSESSMENT:
-Leg pain due to
*Cellulitis
*DVT-> Duplex -
*Lumbar radiculopathy
*Arthritis

PLAN:
-Blood cx x 2
-Unasyn
-CBCD, BMP in AM
-UA
-Tylenol 650 mg PO q 4-6 hr PRN pain/fever
-Home meds
-Heparin 5000 U SQ BID

Signature:


Created: 2/2005
Updated: 03/08/2007