Download Medicine History and Physical PCP: Contact Person: Code Status

Medicine History and Physical
PCP:
Contact Person:
Code Status:
Chief Complaint:
HPI:
4 HPI elements (Location, quality, severity, duration, timing, modifying factors, and associated signs and symptoms) or
the status of 3 chronic or inactive problems.
Genitourinary – External Genitalia without lesions, no masses, bladder without fullness, no vaginal/penile discharge
Musculoskeletal- Inspection (Head, Neck, Spine, Ribs, Pelvis, Bilateral Upper and Lower Extremities) without
misalignment, asymmetry, tenderness or effusions. No changes of range of motion (Head, Neck, Spine, Ribs, Pelvis,
Bilateral Upper and Lower Extremities).
Skin- Overall warm and dry, no lesions, rashes or ulcers
Neuro- CN II-XII intact upon inspection, DTRs intact, proprioception intact bilaterally in upper and lower extremities
Psych- Alert and oriented to person, place, time and situation. Mood good with congruent affect.
Labs:
CBC, Chem 10, LFTs, CBGs, other relevant labs
Micro Cultures:
Blood Cultures date of collection (_/_/_):
Body Fluid Cultures date of collection (_/_/_):
ROS: (Need 10 systems, you pick)
The patient currently denies
(Constitutional) fever chills,
(Eyes) changes in vision, blurry vision,
(ENT) changes in hearing, runny nose, sore throat,
(Cardiovascular) CP, palpitations, lower extremity swelling,
(Respiratory) SOB, cough, wheezing,
(Gastrointestinal) nausea, vomiting, constipation, diarrhea,
(Genitourinary) feelings of dysuria or changes in urination,
(Musculoskeletal) muscle or joint pain, change in range of motion,
(Integumentary) new rashes or changes in skin,
(Neuro) HA, dizziness, numbness, tingling, confusion
(Psych) changes in mood, feelings, or depression,
(Endocrine) changes in weight, feelings of cold/heat intolerance, polyuria/polydipsia
(Heme/Lymph) easy bruising/bleeding, swollen lymph nodes
(Allergic/Immune) frequent infections, seasonal allergies
Past Medical History:
Piror Illness or injuries
Prior Operations
Prior Hospitalizations
Allergies:
Past Family History:
Health status/Cause of Death of Parents, Siblings, Children
Specific Diseases related to the problem related to the Chief Complaint
Disease of family members (DMII, MI, HTN, Cancer)
Social History:
Marital Status/Living arrangements
Current Employment
Alcohol Use
Tobacco Use
Drug Use
Current Outpatient Medications Reviewed:
Active Inpatient Medications
Physical Exam: (Need 2 from 9 systems, you pick)
Vitals: Temp, HR, BP, RR, O2 Sat
General- alert, pleasant, in no acute distress
Eyes – Eyes atraumatic and conjunctiva are non-injected and w/o icterus
Ears Nose, Throat- Ears atraumatic, nose without discharge or erythema, oropharynx without erythema or exudate,
unremarkable dentition, gums appear intact and without blood
Lymphatic- no anterior cervical, posterior cervical, or Axillae/upper extremity lymphadenopathy appreciated
Respiratory- symmetric chest movement with respirations, air movement appreciated throughout all lung fields, clear to
auscultation bilaterally, no use of accessory muscles, no wheezes or crackles
Cardiovascular- regular rate and rhythm, no murmurs, no LE pitting edema appreciated bilaterally, 2+ pedal pulses
GI- abdomen soft, non-distended, bowel sounds present, no pain to deep palpation, no hernias noted
Radiology/Imaging:
Radiologist Impression of CXR:
Radiologist Impression of CT:
Radiologist Impression of MRI:
Cardiologist Impression of TTE:
Gastroenterologist Impression of EGD/Colonoscopy:
Assessment / Plan by Problem (Need at least 4 Complex Problems): (Some Examples)
- COPD Exacerbation due to PNA/allergies/medication non-compliance: Patient with home O2 requirement of _L.
Patient with most recent PFTs on _/_/_.
* Contine albuterol-ipratropium nebulizations _ scheduled/PRN Q4
* Contine abx _ (start _/_/_ to _/_/_)
* Contine to titrate O2 to sats >90%
- Acute on Chronic Decompensated/Compensated Chronic HFrEF (_ EF, TTE _/_/_) (acute decompensated systolic
heart failure): Due to ischemic cardiomyopathy/nonischemic cardiomyopathy. Weight on admission of _ (_/_/_). Cr on
admission of _ (_/_/_).
* Fluid Balance in past 24 hrs of +/- _ ml
* Continue Furosemide _mg Q_
* Continue to monitor
- Compenstated Chronic/Acute on Chronic Decompensated Cirrhosis due to EtOH/Hep C (dx _/_/_):
* Continue Lactulose _ gm and titrate to 4-5 BMs per day
* Continue to monitor
- Controlled/Uncontrolled Diabetes Type II: HbA1c _ (_/_/_). CBG within last 24 hours with range of _ - _ and _
units of correctional insulin used.
* Continue Glargine _ units at bedtime
* Continue _ units Nutritional TID
* Continue Correctional scale
* Continue to monitor POC glucose
- UTI: Probable E. coli
* Contine abx _ (start _/_/_ to _/_/_)
* F/U urine cultures collected on (_/_/_)
- Acute vs Chronic Normocytic/Macrocytic/Microcytic Anemia: Due to chronic disease/blood
loss/cirrhosis/malnutrition (vitamin B12/Folate)/iron deficiency. H/H _ (_/_/_) and MCV _ (_/_/_) on presentation.
Previous iron studies of _ Fe, _ Transferrin, _ Fe saturation, and _ TIBC (_/_/_). _ Vitamin B12 (_/_/_). _ Folate (_/_/_).
_ TSH (_/_/_). S/P transfusion of _ units of RBC/FFP/Platelets.
* Continue to monitor with daily CBC
Hospital Issues:
DVT Prophylaxis: _
Foley/Lines/Restraints: _
Code Status: _
Contact Person/Number: _
Ambulation status: _walks independently, needs assistance, use device, sits in the bed, bedridden and immobile
Discharge Planning:
Likely DC in _ (1-2 days, 3-5 days, >5 days)
Likely Destination: _
Follow-up Appts:
Medicine Progress Note
ID: _ yo M/F with PMH of _ who is admitted for _ that is stable/improving and will remain in the hospital
due to _
24 Hour Events:
Interval History/Subjective:
4 HPI elements (Location, quality, severity, duration, timing, modifying factors, and associated signs and
symptoms) or the status of 3 chronic or inactive problems.
ROS: (Need at least 1 from 9 systems, you pick)
The patient currently denies
(Constitutional) fever chills,
(Eyes) changes in vision, blurry vision,
(ENT) changes in hearing, runny nose, sore throat,
(Cardiovascular) CP, palpitations, lower extremity swelling,
(Respiratory) SOB, cough, wheezing,
(Gastrointestinal) nausea, vomiting, constipation, diarrhea,
(Genitourinary) feelings of dysuria or changes in urination,
(Musculoskeletal) muscle or joint pain, change in range of motion,
(Integumentary) new rashes or changes in skin,
(Neuro) HA, dizziness, numbness, tingling, confusion
(Psych) changes in mood, feelings, or depression,
(Endocrine) changes in weight, feelings of cold/heat intolerance, polyuria/polydipsia
(Heme/Lymph) easy bruising/bleeding, swollen lymph nodes
(Allergic/Immune) frequent infections, seasonal allergies
Current Medications:
Active Inpatient Medications
Physical Exam: (Need 12 bullets from any organ systems, you pick)
Vitals: Temp, HR, BP, RR, O2 Sat
General- alert, pleasant, in no acute distress
Eyes – Eyes atraumatic and conjunctiva are non-injected and w/o icterus
Ears Nose, Throat- Ears atraumatic, nose without discharge or erythema, oropharynx without erythema
or exudate, unremarkable dentition, gums appear intact and without blood
Lymphatic- no anterior cervical, posterior cervical, or Axillae/upper extremity lymphadenopathy
appreciated
Respiratory- symmetric chest movement with respirations, air movement appreciated throughout all lung
fields, clear to auscultation bilaterally, no use of accessory muscles, no wheezes or crackles
Cardiovascular- regular rate and rhythm, no murmurs, no LE pitting edema appreciated bilaterally, 2+
pedal pulses
GI- abdomen soft, non-distended, bowel sounds present, no pain to deep palpation, no hernias noted
Genitourinary – External Genitalia without lesions, no masses, bladder without fullness, no
vaginal/penile discharge
Musculoskeletal- Inspection (Head, Neck, Spine, Ribs, Pelvis, Bilateral Upper and Lower Extremities)
without misalignment, asymmetry, tenderness or effusions. No changes of range of motion (Head, Neck,
Spine, Ribs, Pelvis, Bilateral Upper and Lower Extremities).
Skin- Overall warm and dry, no lesions, rashes or ulcers
Neuro- CN II-XII intact upon inspection, DTRs intact, proprioception intact bilaterally in upper and lower
extremities
Psych- Alert and oriented to person, place, time and situation. Mood good with congruent affect.
Labs:
CBC, Chem 10, LFTs, CBGs, other relevant labs
Micro Cultures:
Blood Cultures date of collection (_/_/_):
Body Fluid Cultures date of collection (_/_/_):
Radiology/Imaging:
Radiologist Impression of CXR:
Radiologist Impression of CT:
Radiologist Impression of MRI:
Cardiologist Impression of TTE:
Gastroenterologist Impression of EGD/Colonoscopy:
Assessment / Plan by Problem: (Some Examples)
- COPD Exacerbation due to PNA/allergies/medication non-compliance: Patient with home O2
requirement of _L. Patient with most recent PFTs on _/_/_.
* Contine albuterol-ipratropium nebulizations _ scheduled/PRN Q4
* Contine abx _ (start _/_/_ to _/_/_)
* Contine to titrate O2 to sats >90%
- Acute on Chronic Decompensated/Compensated Chronic HFrEF (_ EF, TTE _/_/_) (acute
decompensated systolic heart failure): Due to ischemic cardiomyopathy/nonischemic cardiomyopathy.
Weight on admission of _ (_/_/_). Cr on admission of _ (_/_/_).
* Fluid Balance in past 24 hrs of +/- _ ml
* Continue Furosemide _mg Q_
* Continue to monitor
- Compenstated Chronic/Acute on Chronic Decompensated Cirrhosis due to EtOH/Hep C (dx _/_/_):
* Continue Lactulose _ gm and titrate to 4-5 BMs per day
* Continue to monitor
- Controlled/Uncontrolled Diabetes Type II with/without Complications: HbA1c _ (_/_/_). CBG
within last 24 hours with range of _ - _ and _ units of correctional insulin used.
* Continue Glargine _ units at bedtime
* Continue _ units Nutritional TID
* Continue Correctional scale
* Continue to monitor POC glucose
- UTI: Probable E. coli
* Contine abx _ (start _/_/_ to _/_/_)
* F/U urine cultures collected on (_/_/_)
- Acute vs Chronic Normocytic/Macrocytic/Microcytic Anemia: Due to chronic disease/blood
loss/cirrhosis/malnutrition (vitamin B12/Folate)/iron deficiency. H/H _ (_/_/_) and MCV _ (_/_/_) on
presentation. Previous iron studies of _ Fe, _ Transferrin, _ Fe saturation, and _ TIBC (_/_/_). _ Vitamin
B12 (_/_/_). _ Folate (_/_/_). _ TSH (_/_/_). S/P transfusion of _ units of RBC/FFP/Platelets.
* Continue to monitor with daily CBC
Hospital Issues:
DVT Prophylaxis: _
Foley/Lines/Restraints: _
Code Status: _
Contact Person/Number: _
Ambulation status: _walks independently, needs assistance, use device, sits in the bed, bedridden and
immobile
Discharge Planning:
Likely DC in _ (1-2 days, 3-5 days, >5 days) pending reason for being in the hospital
Likely Destination: _
Follow-up Appts: _