e-MedTools

New Inpatient Evaluation (History and Physical) – Upload a Document to Scribd

Read this document on Scribd: New Inpatient Evaluation (History and Physical)

New Inpatient Evaluation Date Allergies Medications MRN Chief complaint/Reason for consult History of present illness Start time Stop time Social History  Tobacco use ____ Packs x ____ Yrs  Quit Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems  >/= 2 Falls within past 12 months, OR 1 which resulted in injury 4  Alcohol use ______ Drinks per  day  week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day  Recreational drug use  Injectable  Inhalational  Ingestible  Prescription Drug Dependence  Narcotics  Benzodiazepines See HPI WNL  Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite  Eyes Vision changes, New pain, Scotomas  ENT/mouth Nose bleeds, dental caries, dental abscess, jaw pain  Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea  CV Chest pain, diaphoresis, ankle edema, PND, syncope, claudication symptoms  GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena  GU Change in urinary habits, hematuria, dysuria  Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling  Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun  Neuro Seizures, episodic or chronic muscle weakness  Endo Hair loss, polydipsia  Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes  Allergy/Immun Sinus probs, recurrent infections  Psych Mood changes, agitation, psychosis, delirium, dementia Occupational History Family Medical History  Asthma  Congestive Heart Failure  COPD  Coronary Artery Disease  Premature Onset  Diabetes  Malignancy  Neuromuscular weakness  Obstructive Sleep Apnea  Pancreatitis  Peripheral Artery Disease  Renal Dysfunction  Thyroid Disease Past Medical and Surgical History Asthma Hypertension  Pulmonary HypertensionSurgeries Autoimmune disease Malignancy  Renal Dysfunction Cerebral Artery Disease Chemotherapy Rheumatic fever Congenital heart defects Radiation exposure Seizure Disorder COPD Myocardial infarction Shunt Coronary Artery Disease Stent placement  Steroid use Diabetes Type 1 Type 2 Neuromuscular weakness Thrombotic Disease GERD Obstructive Sleep Apnea Thyroid Disease Heart Failure CPAP BiPAP  Valvular disorders Hepatitis Occupational exposures HIV/AIDS Peripheral Artery Disease  CABG  Cardiac Catheterization  Stress Test  ECHO  Mammogram  PapSmear  PFTs  Colonoscopy ©MB and RR 2006, 2007 Revised 16June07 New Inpatient Evaluation Vaccines Flu Pneum Vitals Weight Height Temperature BP Sitting BP Standing Pulse Sats CVP Cardiac Output Urine Output/24 hrs Urine Output/8 hrs BCG Tetanus Pertussis Varicella Exam Ventilator Settings Mode Rate Tidal Vol PEEP PS FiO2 PO2/FiO2 Plateau Pressure NonInvasive Ventilator (CPAP, BiPAP) Settings  Alert  Conjunctivae Pupils Discs ENT TM Pharynx Dentition  Nasal External ears  Hearing Neck  Exam  Thyroid Resp  Clear to auscultation  Clear to percussion Effort Normal to palpation CV  Auscultation  Palpation  Edema Carotids  Aorta Femoral pulses  Pedal pulses GI  Abdomen  No hepatosplenomegaly  No hernias  Rectum  Guaiac Breasts  Inspection Palpation GU  Scrotum  Penis  Prostate  Urethra Gyn  External  Bladder  Cervix  Uterus  Adnexa Lymph  Neck  Axilla  Groin  Other Musc  Gait  Digit  Inspection  ROM  Stability  Strength Skin  Inspection  Palpation Neuro  CN  DTR  Sensation  Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Psych  Affect  Insight  Memory General Eye Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Impression and Plan Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Data Reviewed  Past Medical History  Social History  Family Medical History  Allergy list  Medication list  Labs/Tests  ER Notes  Old Chart  EMS Note  ECG  Nursing Notes & Vitals log  Radiology studies Care coordinated with ER MD HCPOA PCP Case Management Social Worker Pharmacy Nutrition team Physical therapy Respiratory therapy Nursing staff ©MB and RR 2006, 2007 Carotid Dopplers, Neck CT Angiography, MR Angiography11 Pts with ischemic stroke or transient ischemic attack CT or MRI of head within 24 hrs of admission10 Pts with ischemic stroke or transient ischemic attack Hemoglobin A1c level1 ACE Inhibitor/ARB therapy5 Pts with heart failure + left ventricular dysfunction Aspirin within 24 hrs of admission for AMI 28 Beta-blocker therapy 29, 7,8 Pt with AMI, CAD + prior MI, and heart failure + left ventricular dysfunction DVT prophylaxis Intense glycemic control Stress ulcer prophylaxis Sedation vacation – daily Changing central lines Enteral/Parenteral feeds Flu vac prior to discharge Head of bed elevated > 30 deg at all times Pneum vac prior to discharge Physical therapy Pulmonary toilet – aggressive Speech therapy evaluation Hospice Consult Ethics Consult Smoking Cessation Counseling Provided Revised 16June07 New Inpatient Evaluation Signature  Patient has completed advanced health care directives47 CODE STATUS Patient is a FULL CODE HCPOA is DNAR DO NOT ATTEMPT RESUSCITATION ©MB and RR 2006, 2007 Revised 16June07

Template updated on 11/16/08