Transcription of 1 .5 ID 2. 6. d 3. 7. Contact Code 4status
1 Name Allergies Home Meds MRN Room 1. 5. ID 2. 6. 3. 7. d Contact Code status 4. 8. continue CC. HPI Fam Hx Physical Exam T BP HR RR O2. Orthostat 1. Gen HEENT/N. R. 2. Soc CV. Abd Rec/GU. 3. Lymph MSK. Skin 4. Neuro Psych 5. ED Admit Meds Vitals Diet: IVF: 1. 2. 3. 4. 5. ROS Const: sick contacts, fever, chills, wt loss, malaise, weakness, dizziness, appetite HEENT: blurry vision, 6. photophobia, vision, hearing, sore throat, tinnitus, 7. drainage Resp: SOB, cough, sputum, pleuritic chest pain, 8. hemoptysis Card: orthop, PND, DOE, LE edema, pain chest/ DVT Proph GI proph left arm/ shoulder/ neck/ jaw/ back, syncope, palp, ECG: claudication GI: N, V, regurg, heartburn, odynophagia, Prn meds dysphagia for solids/liquids, abd pain, diarrhea, constipation, Tylenol 650 PO q6 (pain).
2 CXR: bloat, hemetem, melena, hematochezia, mucus GU: urgency/ Vicodin _ tab PO q4. frequency/ incontinence, dysuria, hematuria, hesitancy, post- Accuchecks/ISS. void dribbling, impotence, testicular masses,vaginal dc, Studies MOM 15 cc POq4 cont dyspareunia, bleeding Endo: thirst, polyuria, heat/ cold intole, Metoclop 10 mg IV q6 N. tremor, menstrual irreg, hair/ skin/ nails, libido, body hair Skin: rashes, itch Breast: masses, pain, discharge, Temazepam 15 mg PO qh lactation Msk: arthralgias, deformity, swelling, myalgias, Benadryl 25mg PO q muscle weakness Hematologic: bruising, h/o excessive Meds Comp 10mg IM/PO naus bleeding, LAD Neurologic: HA, focal weakness, seizure, tremor, falls, memory loss, paresthesias, sensory loss, vertigo Psychiatric: Sleep/ interest/ guilt/ energy/ concentration/.
3 Appetite/ psychomotor/ suicide Additional Labs/Pending A/P. 1. 1. PMH DDX 2. 1. Plan 3. 4. 2. 2. 5. DDX 6. 3. Plan 7. 8. 4. 3. 5. DDX. PSH Plan To Do 1. 2. 4. DDx Meg2007. Meg Skibitsky Skibitsky 2007 Meg Pla
