Date of Admission:
Resident: Kenneth Acha, MD, UCR FM PGY2
Attending:
PCP:
Specialists:
Reason for Admisson:
HISTORY OF PRESENT ILLNESS:
____ yo M/F with a history of …. who presents with a….
At baseline, the patient is….
Pt was in usual state of health until __ days prior to admission when….
In the ED, patient received….
REVIEW OF SYSTEMS:
Positive Review of Symptoms mentioned and elaborated on in HPI.
Head: Denies H/A, trauma, loss of consciousness.
Eyes: Denies visual loss, diplopia.
Ears: Denies: deafness, tinnitis, discharge, pain
Nose: Denies discharge, obstruction, epistaxis
Mouth: Denies sores, gingival bleeding, jaw pain
Neck: Denies stiffness, issues swallowing.
Respiratory: Denies cough, sputum, SOB
Cardiovascular: Chest Pain, Palpitations
Gastrointestinal: Denies melena, abd pain, n/v/d
Genitourinary: Denies dysuria, discharge.
Skin: Denies: lesions, rashes, pruritis.
Musculoskeletal: Denies joint pain, swelling or increased warmth.
Neuro: Denies numbness, tingling, weakness.
Psyc: Denies feelings of anxiety and depression at this time.
PAST MEDICAL & SURGICAL HISTORY:
Problems List (Across Visits)
FAMILY HISTORY:
Non-contributory
SOCIAL HISTORY:
MEDICATIONS:
PHYSICAL EXAMINATION
*Vital Signs
General: NAD, well developed, well-nourished. Cooperative.
Psychiatric: AOX3
HEENT: NC / AT, PERRL, EOMI, Conjunctivae are pink and anicteric. normal dentition, normal mucous membranes, oral mucosa well hydrated.
Lymphatics: No palpable lymphadenopathy
Neck: Supple, painless range of motion
CV: Normal S1 S2, RRR, no M/R/G, no heaves or thrills. Chest is non-tender to palpation. No JVD, no edema, warm, well perfused, + 2 DP / PT pulses.
Respiratory: CTAB, no W/R/R, no use of accessory muscles of respiration.
GI: Soft NT / ND normal BS, No HSMG, no hyperesonance. No guarding or rebound tenderness.
Skin: No rashes or lesions
Musculoskeletal: FROM, no synovitis
Neurologic: CN II-XII grossly intact, sensation, strength, reflexes, cerebellar function, gait in tact. No focal neurologic deficits.
ASSESSMENT AND PLAN
PLAN
-**ADC VANDALISM – Go through each time you write admit assessment/plan.
-** For each problem. Say what has been done. What the current status is. What you plan to do. What your end result is.
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#GI Prophylaxis
#DVT Prophylaxis
Enoxaparin 40mg SC qd
#Code Status: Full Code
Patient verbalized understanding of the implications of his decision.
Resident Statement: The attending physician personally examined and thoroughly discussed and directed the plan of care for this patient.
Kenneth Acha, MD
Family Medicine PGY2 Resident
University of California in Riverside