H&P

For H&P in PDF format clicks here.

Name:_____ Age:____ Sex:____

CC:

HPI: History of present illness – NLDOCAT

  • Nature
  • Location
  • Duration
  • Course
  • Aggravated by
  • Treatment

Denies fevers, chills, nausea, vomiting (FCNV) or shortness of breath (SOB). Any previous trauma? Last meal (NPO status)? Neurovascular intact? Open injury? what happened at the time of the incident?

PMH: Past medical history – IMAHO

  • Illnesses/Diagnosis
  • Medication
  • Allergies
  • Hospitalization
  • Operations

SH: Social history

  • Hx of smoking? how many years? pack years?
  • Hx of EtOH? how many drinks a week
  • Any recreational drugs?
  • Current occupation? work? retired?
  • Support system? married? wife or kids?

FH: Family history

  • Mom – deceased? illnesses? diabetes? cancer?
  • Dad –

ROS: Review of Systems

  •        Constitutional – denies weight loss/gain, f/ns/c
  •        Eyes – denies visual changes
  •        ENT – denies nasal congestion, dysphagia
  •        Skin – denies rashes
  •        Cardiovascular – denies chest pain, palpitations
  •        Pulmonary – denies sob, cough
  •        Endocrine – denies p/p/p
  •        Gastrointestinal – denies abd pain n/v/d melena
  •        Genitourinary – denies dysuria/frequency, discharge
  •        Musculoskeletal – denies joint aches
  •        Neurologic – denies syncopal episodes, headaches/migraines
  •        Psychology – denies mood changes
  •        Heme/Lymph – denies easy bruising

VITALS:

PHYSICAL EXAM:

  • General: WDWN, NAD, sitting in chair
  • HENT: ncat; mmm; oropharynx clear; no cervical lad
  • Eyes: eom wnl; no pallor injection or icterus
  • Cardiovascular: rrr; no m/r/g. A-fib on telemonitor, in 100s range
  • Pulmonary: CTAB
  • Abdominal: soft, NDNT, incision c/d/i
  • Neurological: MAE
  • Extremities: no edema, erythema, openings, or lacerations
  • Skin/Wound: 1 x 1 cm left lateral ankle wound; mild surrounding erythema
  • Neuro: a&ox4; cn grossly intact; responding appropriately; moving all extremities; Dix-Hallpike negative
  • Psych: normal mood/affect

Pulse Exam:

                                 R L

Femoral                  2 2

Popliteal                 2 2

Posterior Tibial     2 2

Dorsalis Pedis        2 2

Vascular Exam:

  1. Inspection: No rashes, swelling, color change, or cyanosis in arms.
  2. No signs of venous stasis in legs and no pigmentation around ankles.
  3. No spider veins on legs and thighs bilaterally.
  4. No clubbing in fingernails. Capillary refill is 2 sec.
  5. Palpation: Hands warm and pink.
  6. Feet are a bit cool to the touch and pale, but equal bilaterally.
  7. No edema in feet.
  8. No ulcers in lower extremities.

LABS:

MICRO: NONE

IMAGING:
#XR L Foot 04/21/2050
Pending Post-op views

#XR Chest 04/21/2050
Enlarged cardiac contour, consistent with cardiomegaly and/or pericardial
effusion. Perihilar vascular congestion without frank pulmonary edema.  No
pleural effusion or pneumothorax.

PATHOLOGY: Pending Left hallux

ASSESSMENT & PLAN:

ENDO
# T2DM

  • ISS Algorithm 2
  • Insulin glargine 12 units

INTEGUMENTARY/EXTREMITIES
# L 5th partial toe amputation

  • (+)Corynebacterium Jaekaeium growth – micro final
  • Post Op #12 days from Left 5th ray resection
  • L foot only heel weight-bearing
  • Heparin 5000u SQ TID
  • Post-op shoe dispensed to be worn on L foot
  • Cefepime 2g IV Q12H, vancomycin 750mg IV Q12H
  • Prevalon boots to be worn while in bed.
  • Dressings: Betadine paint, Owens silk, and dry sterile dressings.

 

PLAN

Bellow is a sample list of each diagnosis and treatment. Commonly seen in internal medicine, vascular, ID, and trauma rotations

NEURO/PSYCH
# Pain Management

  • tylenol, tramadol, oxy, Dilaudid, baclofen for pain

# Tremor – Patient with b/l DBS placement for tremor

  • Propanolol 120mg PO

CV
# s/p L fem-below knee pop jump graft w/ complex closure with Plastics.

  • LLE NWB, PT/OT to mobilize
  • diabetic diet
  • qAM CBC, BMP
  • no abx
  • Continue home meds (eg amtriptyline for PTSD, atorvastatin, sleep
    medications
  • Abx Cefazolin on until drains removed.

PULM
# O2 requirement: improving

  • Hx of COPD, continue albuterol and budesonide

FEN/GI/GU

  • NPO+ sips
  • LR @125
  • Foley, monitor urine output closely (suprarenal cross-clamp time 40 min)
  • IV protonix, gi prophylaxis
  • Foley removed and voiding after surgery

# GERD

  • Pantoprazole 40mg

# Constipation

  • Docusate 250 NA CAP
  • Senna 17.2 Tab PO
  • Bisacodyl 10

HEME/ID
# lymphocytosis w/ + smudge cells

  • WBC improving post-operatively but lymphocyte predominance with atypical
    lymphocytes concerning for CLL.
  • Peripheral smear + smudge cells
  • LDH low; Flow cytometry pending
  • F/u ordered Labs PENDING on the beta-2 glycoprotein, PNH, Cardiolipin ABS

ANTICOAGULATION

  • ASA 81 in AM
  • Heparin 5000u SQ BID

ENDO
# T2DM

  • ISS Algorithm 2
  • Insulin glargine 12 units

# HTN – (BP 194/91)

  • Hydralazine 50 BID, amlodipine 10 daily
  • Amlodipine TAB 10mg PO
  • EKG reviewed, no abnormalities noted
  • 10 IV Hydral

# HLD

  • Atorvastatin 20mg QHS

INTEGUMENTARY/EXTREMITIES
# L 5th partial toe amputation

  • (+)Corynebacterium Jaekaeium growth – micro final
  • Post Op #12 days from Left 5th ray resection
  • L foot only heel weight-bearing
  • Heparin 5000u SQ TID
  • Post-op shoe dispensed to be worn on L foot
  • Cefepime 2g IV Q12H, vancomycin 750mg IV Q12H
  • Prevalon boots to be worn while in bed.
  • Dressings: Betadine paint, Owens silk, and dry sterile dressings.

DISPO

  • F/u PTOT
  • Possible discharge this coming week. Likely SNF, SW to review case today.
  • F/u with Vasc, Podiatry, and Plastics. Will arrange for a clinic visit.
  • Uses walker @ b/l and post-op shoe