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Beth Israel Deaconess Medical Center Department of Medicine Attending Note Date

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									Department of Medicine Attending Note
Date:
PCP:
Family:                                                                                                 Patient addressograph
         Initial Inpatient Visit   Consultation. Requested by:

Chief Complaint/Dx:
 I have seen the patient, reviewed the note of Dr. _______________ from __________ and agree with the history,
PFSH & ROS. I would like to add the following remarks:                      date

HPI:




PMH:




Meds:




Allergies:         NKDA
SH:


FH:


Review of Systems
Yes    No    Constitutional           wnl       Yes No Respiratory               wnl       Yes No Skin                              wnl
           Weight loss                                Shortness of breath                       Rash
           Fatigue                                    Pleuritic pain                            Pruritis
           Fever                                      Hemoptysis                                     Endocrine                    wnl
           Chills / Rigors                            Cough                                     Change in skin/hair
           Night sweats                                    Gastrointestinal     wnl              Loss of energy
           Anorexia                                   Nausea                                    Weight change
             Eyes                     wnl              Vomiting                                       Musculoskeletal              wnl
       Blurry vision                                  Hematemesis                               Myalgias
       Diplopia                                       Hematochezia                              Arthralgias
       Loss of vision                                 Abdominal swelling                        Back pain
       Photophobia                                    Abdominal pain                                 Neurological                 wnl
             ENT                      wnl              Diarrhea                                  Numbness of extremities
       Dry mouth                                      Constipation                              Weakness of extremities
       Oral ulcers                                         Heme/Lymph           wnl              Paresthesias
       Bleeding nose/gums                             Bruising                                  Dizziness
       Tinnitus                                       Lymphadenopathy                           Vertigo
       Sinus pain                                          Genitourinary        wnl              Confusion
       Sore throat                                    Dysuria                                   Headache
             Cardiac                  wnl              Hematuria                                       Psychiatric                 wnl
       Chest pain                                     Urinary incontinence                      Depression
       Palpitations                                   Frequency                                 Suicidal thoughts
       Lower ext. edema                               Urgency                                        Allergy/Immunological        wnl
       Orthopnea                                                                                  Medication allergies
       PND
Level of History: Problem focused = CC, 1 –3 HPI;                             Expanded Problem Focused = CC, 1 – 3 HPI, 1 ROS;
                     Detailed = CC, 4 + HPI, 2 – 9 ROS, 1 PSFH                Comprehensive = CC, 4+ HPI, 10+ ROS, 2/3 or 3/3 PFSH
  HMFP Compliance, April 2001 Form # MC1133
Physical Examination
SYSTEM/BODY AREA                                          DETAILS
Constitutional
    Vital Signs              T                               BP                          HR                    HT
(document at least three)     O2 Sat                          BP                          HR                    WT
                              RR
    General appearance        NAD                           Cachetic                Fatigued          Finger Sticks:
                                                              Ill appearing           Uncomfortable
Psychiatric
   Orientation                  A&O x 3                     A&O x ___
   Mood and affect              wnl
   Judgement and insight        wnl
   Memory                       wnl
Eyes
   Conjunctiva or lids          wnl                         icteric          pale
   Pupils or irises             PERRL
   Ophthalmoscopic              wnl
Ears, Nose, Mouth & Throat
   External Inspection          wnl
   Hearing                      wnl
   Otoscopic                    wnl
   Nose                         wnl
   Mouth                        Mm moist                   Mm dry
   Oropharynx                   wnl
Neck
   Examination                  supple
   Thyroid                      no mass/thyromegaly
Lymphatic
   Neck                         none
   Axillae                      none
   Groin                        none
   Other (supraclavicular)      none
Respiratory
   Effort                       comfortable                labored
   Ausculation                  CTA B/L
   Percussion                   wnl
   Palpation                    wnl
Cardiovascular
   Auscultation                 RRR                        Irreg. irreg
                                 No M/R/G                   No JVD
   Palpation                    wnl
Examination of:
   Carotid arteries             normal pulsation           no bruits
   Abdominal aorta              normal pulsation           no bruits
   Femoral arteries             normal pulsation           no bruits
   Pedal pulses                 normal pulsation
   Extremities for edema        no edema
Gastrointestinal
   Examination                  soft      NT              no rebound
                                 NABS      ND              no guarding
   Liver and Spleen             no organomegaly
   Rectal exam                  wnl
   Occult blood test            negative
   Exam for hernias             wnl
Neurologic
   Cranial nerves             II – XII intact
   Deep tendon reflexes       2 + biceps bilaterally
                               2 + patellar bilaterally
                               Babinski wnl
    Sensation                 normal light touch
                               FTN wnl bilaterally
Musculoskeletal               Range of motion            Muscle strength and tone       Inspection & Palpation         Stability
  Upper Extremities            FROM                      5/5 bilaterally

    Lower Extremities            FROM                      5/5 bilaterally

    Head and Neck                FROM                      wnl

    Spine, Ribs and Pelvis       FROM                      wnl

    Gait and station             wnl
    Digits and Nails             wnl
SYSTEM/BODY AREA                                           DETAILS
   Skin
   Inspection                    no rash
   Palpation                     wnl
Chest/Breast
   Inspection                    symmetric
   Palpation                     no masses
Genitourinary
Female:                                                                         Male:
   External genitalia                                                               Scrotal contents     no testicular masses
   Uretheral exam                                                                   Penile exam          wnl
   Bladder exam                                                                     Digital rectal exam  normal prostate
   Cervix
   Uterus
   Adnexa/Parametria
Level of Physical Exam: Problem Focused = 1 organ system/body area Expanded Problem Focused = 2 – 4 organ systems/body areas
                       Detailed = 5 – 7 organ systems/body areas   Comprehensive = 8 body systems/body areas or a complete organ review




Medical Decision Making

Labs:

                                                                  PT /INR                 ALT                     Alb
                                                                  PTT                     AST                     Ca
                                                                                          Alk Phos                Phos
                                                                                          TB                      Mg
                                                                                          Amylase                 Lipase
                #1       #2        #3
CK
MB

cTnI

U/A:

UCx:

BCx:

Stool Cx:

ECG:

CXR:




Impression and Plan:
   DNR status discussed: Full code   DNR   DNI




M.D. Signature: ________________________
Time spent: ________ mins

								
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