EXAMPLE
Nimisha Shah, M.D.
HISTORY AND PHYSICAL
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CHIEF COMPLAINT: Fever, cough, altered mental status.
HISTORY OF PRESENT ILLNESS: The patient is a 93-year-old female,
Spanish-speaking, with a history of hypertension, thyroid
carcinoma status post thyroidectomy, chronic atrial fibrillation
on chronic anticoagulation, has a history of dementia who was
brought to the ER with a chief complaint of high-grade fever, Tmax 102, productive cough, chest congestion, and shortness of
breath for a week. She was evaluated by her primary care
physician at Stanford Medical Center a week ago and received a
dose of Rocephin and some oral antibiotics; however, no
satisfactory response was noted, and so her daughter brought her
to the Emergency Room. With the patient being a poor historian
and mildly sedated at the time of interview, most of the history
was obtained from the ER nurse and the chart.
There is no history of hemoptysis, nausea or vomiting. There is
a history of decreased oral intake and feeling more lethargic for
the last few days.
PAST MEDICAL HISTORY: Hypertension; Thyroid carcinoma status post
thyroidectomy; Chronic atrial fibrillation on chronic
anticoagulation; Cardiomyopathy (?); History of dementia.
PAST SURGICAL HISTORY: Left total knee replacement; Hysterectomy;
Thyroidectomy.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS: Metoprolol, thyroid (Armour), Cozaar, warfarin,
aspirin, hydrochlorothiazide.
SOCIAL HISTORY: She is a resident of Gilroy.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a 93year-old elderly female lying on bed and sedated but arousable
and confused with no acute distress. VITAL SIGNS: T-max 97.8,
pulse 102, respiratory 26, blood pressure 144/49, O2 saturation
93% on 3 liters nasal cannula. HEENT: Atraumatic, normocephalic,
dry oral mucosa. Eyes: Pupils equally reactive to light and
accommodation. Extraocular movements intact. NECK: Supple. No
thyroid swelling. No JVD. LUNGS: Bilateral expiratory wheezing
and scattered crackles heard. CARDIOVASCULAR: S1, S2 regular.
No gallop or murmur heard. ABDOMEN: Bowel sounds present. Soft,
nontender. No organomegaly. CENTRAL NERVOUS SYSTEM: Lethargic
but arousable and confused. Able to obey simple commands. No
obvious focal neurologic deficit noted. EXTREMITIES: No pedal
edema. Peripheral pulses 1+. No cyanosis or clubbing. Homans
sign negative.
LABORATORY DATA: WBC 7.6, segments 68, bands 15, lymphocytes 15,
hemoglobin 9.4, hematocrit 28, platelets 237. Sodium 133,
potassium 3.9, chloride 94, CO2 29, BUN 22, creatinine 1, AST 36,
ALT 23, alkaline phosphatase 81, CK 133, CK-MB 0.4, troponin less
than 0.04, pH 7.48, pCO2 41, pO2 83, O2 saturation 97% on 3.5
liters via nasal cannula. PT 18.8, INR 2, PTT 26. URINALYSIS:
Specific gravity 0.1025, LE negative, WBC 0 to 2, bacteria few.
DIAGNOSTIC DATA: Chest x-ray: No acute infiltrated noted.
Electrocardiogram: Atrial fibrillation with ventricular rate of
120 per minute; no acute ST-T changes.
ADMITTING DIAGNOSES:
1.
Acute asthmatic bronchitis.
2.
Anemia of unclear etiology.
3.
History of chronic atrial fibrillation on chronic
anticoagulation with therapeutic INR.
4.
Mild hyponatremia.
5.
History of dementia with worsening of mental status
secondary to above problems.
PLANS:
1.
Admit to med/surg.
2.
IV hydration with D5 normal saline.
3.
IV antibiotics, Rocephin with Zithromax.
4.
Xopenex nebulizer treatment and supplemental nasal O2 to
maintain O2 saturation more than 92%.
5.
Will obtain anemia workup including stool for blood and
iron studies.
6.
Oral H2 blockers.
7.
To resume her home medications: metoprolol, Synthroid, and
Coumadin. Will hold Cozaar.
8.
Obtain old records from Stanford Medical Center.
9.
Will discuss with family member power of attorney about her
baseline mental status and code status.