1. Date of Service: 2. Primary care Physican 3. Chief Complaint:: 4. HPI: Mr./Ms. _______ is a _______years old male/female with a PHHx of ______, _______, presents to the ED today with complaints of …… -she has been on her baseline state of health until… -who has multiple comorbidities including… -No known aggravating or relieving factors… -Neuro: any focal neurologic complaints or otherwise, triggers for headache… - Abdomen—no hematochezia ( cancer, colitis, ulcer), diarrhea, no constipation… - Denies CP or pressure, palpitations, SOB, cough hemoptysis, N/V, dizziness, syncope, diarrhea, fever, chills, rigors, or abdominal pain (if all negative) - Cardiology eval ( if coming in with Afib, poss. Cardiac issues) - reports no contacts with anyone ill - Sepsis: Febrile, any wound infections or skin abnormalities. Fever, chills, or rigors. - At time of the interview, pt. states that he is feeling better after receiving ______ - Not feeling back to baseline - well known to our medical service from previous admissions, who has had a complex medical history involving… - it is difficult to obtain any meaningful history from the patient. - lacks insight to his medical condition, is somewhat of a limited historian. - extracting a hx from him is somewhat difficult, only answers yew or no to most questions. - Due to … he was referred to our service for admission and further management. 6. Past Medical History: 7. Past Surgical History: 8. Family History: (noncontributory at this time)..Pt. denies any familial diseases or historical findings are obtained from medical records. 9. Social History: job, life stressors, recent travel hx (esp. with any communicable disease) - family health problems (esp. those that he has) - pt. lives alone, ALF, caretaker - history of smoking, drinking or illicit drugs use 10. Allergies: 11. Medications: 12. Review Of Systems: A 14 point review of systems obtained. Pertinent positives as described above, otherwise grossly unremarkable. 13. Physical Examination: Vital signs… GENERAL: At the time of evaluation, pt. appears in no apparent distress. - Chronically ill appearing _____ year old male. He is pleasant and cooperative. - currently in no apparent respiratory distress, however , is utilizing supplemental oxygen via NL, mask… - well developed, well nourished Caucasian male, in no acute distress. - appears tired and fatigued. - appears chronically ill, cachectic, older than her stated age, resting in bed on nasal cannula and no overt resp. distress. HEENT: Normocephalic, atraumatic. Pupils – equal, round and reactive to light. EOMI. Nares patent. Oral mucosa – moist, anicteric - dry oral mucosa, poor dentition - Surgical changes in the ___ eye. - Temporal wasting noted. NECK: Supple, no carotid bruits. No lymphadenopathy. Thyroid nontender. CARDIOVASCULAR: S1, S2. Regular rate and rhythm. No murmurs, gallops or rubs. Pulses present B/L with no peripheral edema. - pacemaker in left sternal border and its easily palpable. - Irregularly irregular (Afib) - Distant heart sounds (if obese) - Unable to verify JVD due to morbid body habitus. RESPIRATOY: _____ to auscultation bilaterally, symmetrical chest excursion. Breathing is even and unlabored. - shallow breathing, poor respiratory effort. - no use of accessory muscles - able to speak full sentences without any SOB GI: Tenderness (rebound of stationary), guarding, protuberant, scars - soft, round, nontender, obese, positive bowel sounds throughout - tenderness in the epigastrium with guarding, but no rebound or rigidity. - No masses palpated. - PEG in place, no extravasation of TF. EXTRIMITIES: Pt. does have 2+ pitting edema to B/L lower ext. and chronic venous stasis changes noted to the skin. - there is no acute infection or ulceration noted. - Pulses palpable, cap refill <3 sec - no clubbing, cyanosis or edema - AV fistula, + for bruit and thrill SKIN: Warm and dry to touch. No rashes, petechiae or lesions noted. NEUROLOGIC: CN II through XII grossly intact. Moves all ext. No focal neurological deficits noted. Symmetrical facial grimace. No slurring of speech. No sensory loss, just diffuse weakness. Gait steady or unable to assess gait at this time PSYCH: AAOx3. Able to answer questions appropriately. Has good insight. 14. Laboratory Data: include any cultures done and pending results. 15. EKG: 16. Imaging: CXR, CT, MRI …. 17. Assessment/Plan: 1. Chief complaint / ? treatment 2. next problem / ? treatment 3. next problem / ? treatment 4. most pertinent medical hx problem / continue home meds 5. DVT - GI prophylaxis / (lovenox for renal pts. , no Pepcid for thrombocytopenic pts. ) , SCDs Disposition: the patient will be admitted under the hospitalist service to the _____ unit. Further orders as his clinical course and response to therapy dictates. - No evidence of pulmonary infection at this time based on his CXR and CT. - Progressive decline is related to refractory… and will require long term care if doesn’t improve with treatment of the aforementioned medical conditions. - Appreciate the prompt input of the intensivist review/ Dr. ______ for cardiology. - If there’s no evidence of ACS, pt will likely be safely discharged home. - Thank you, Dr. _______ for allowing us to participate in the care of this pt.