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Megs History Physical

This document contains a medical record for a patient visit. It includes sections for patient information, history, exam findings, assessments, plans and orders. The record contains detailed information about the patient.

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sgod34
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117 views1 page

Megs History Physical

This document contains a medical record for a patient visit. It includes sections for patient information, history, exam findings, assessments, plans and orders. The record contains detailed information about the patient.

Uploaded by

sgod34
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Meg Skibitsky 2007Meg

d














































Name Allergies
MRN Room
ID

Contact Code status
CC
HPI


1.


2.


3.


4.


5.

ROS Const: sick contacts, fever, chills, wt loss, malaise,
weakness, dizziness,! appetite HEENT: blurry vision,
photophobia, ! vision, ! hearing, sore throat, tinnitus,
drainage Resp: SOB, cough, sputum, pleuritic chest pain,
hemoptysis Card: orthop, PND, DOE, LE edema, pain chest/
left arm/ shoulder/ neck/ jaw/ back, syncope, palp,
claudication GI: N, V, regurg, heartburn, odynophagia,
dysphagia for solids/liquids, abd pain, diarrhea, constipation,
bloat, hemetem, melena, hematochezia, mucus GU: urgency/
frequency/ incontinence, dysuria, hematuria, hesitancy, post-
void dribbling, impotence, testicular masses,vaginal dc,
dyspareunia, bleeding Endo: thirst, polyuria, heat/ cold intole,
tremor, menstrual irreg, ! hair/ skin/ nails, ! libido, ! body
hair Skin: rashes, itch Breast: masses, pain, discharge,
lactation Msk: arthralgias, deformity, swelling, myalgias,
muscle weakness Hematologic: bruising, h/o excessive
bleeding, LAD Neurologic: HA, focal weakness, seizure,
tremor, falls, memory loss, paresthesias, sensory loss, vertigo
Psychiatric: Sleep/ interest/ guilt/ energy/ concentration/
appetite/ psychomotor/ suicide

PMH
1.

2.

3.

4.
5.
PSH
1.
2.
Fam Hx






Soc
ED
Vitals









ECG:

CXR:

Studies




Meds







A/P
1.
DDX
Plan

2.
DDX
Plan

3.
DDX
Plan

4.
DDx
Plan
Physical Exam
T BP HR RR O2
Orthostat
Gen
HEENT/N
R
CV
Abd
Rec/GU
Lymph
MSK
Skin
Neuro
Psych

Home Meds
1. 5.
2. 6.
3. 7.
4. 8.
continue
Admit Meds
Diet:
IVF:
1.
2.
3.
4.
5.
6.
7.
8.
DVT Proph GI proph
Prn meds
Tylenol 650 PO q6 (pain)
Vicodin _ tab PO q4
Accuchecks/ISS
MOM 15 cc POq4 cont
Metoclop 10 mg IV q6 N
Temazepam 15 mg PO qh
Benadryl 25mg PO q
Comp 10mg IM/PO naus

Additional
Labs/Pending

1.
2.
3.
4.
5.
6.
7.
8.

To Do



Meg Skibitsky 2007 www.medfools.com

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