Docstoc

Beth Israel Deaconess Medical Center Department of Medicine Attending Note Date

Document Sample
Beth Israel Deaconess Medical Center Department of Medicine Attending Note Date Powered By Docstoc
					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

				
DOCUMENT INFO