Identifying Data:

Assessed on:
Source:

CC: “______’’

HPI:
____ is a____ year-old-____ with a history of ______ who was in his _______ state of health
until _____ prior to admission.
Onset
Pall/promote
Quality
Radiating
Severity
Timing

Pertinent positives suggesting primary diagnosis.

Also ask about manifestations outside of the system in focus.
Pertinent negatives ruling out significant secondary diagnosis.

PMHx:
________ – Diagnosed clinically by _____. (Un)controlled on ____RX____.

Allergies:
No known allergies.

Meds:
XXXXX
· Dosage: q and route.
Pt endorses taking all medications as prescribed.
Pt denies any multivitamin, over-the-counter supplements or herbal use.

Past Surgical History:

No significant past surgical history.

Family History
Mother:
Father:
No other relatives mentioned.

Social History
Denies any recent alcohol use.
Denies tobacco use.
Denies illicit drug use.
Denies any recent travel.
Able to functionally perform ADLs and IADLs without assistance.
TELL STORY.

Review of Systems:
Refer to HPI when necessary.
Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No
Malaise
ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No
Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty
Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes
Cardiovascular: No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No
Palpitations
Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea
Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain, No
Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No
Jaundice
Genitourinary: No Dysmenorrhea, No DUB, No Dyspareunia, No Dysuria, No Urinary Frequency,
No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes,
No Hesitancy
Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back
Pain, No Neck Pain, No Injury History
Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple
Discharge
Neuro: No Weakness, No Numbness, No Paresthesias, No Loss of Consciousness, No Syncope,
No Dizziness, No Headache, No Coordination Changes, No Recent Falls
Psych: No Insomnia, No Personality Changes, No Delusions, No Rumination, No SI/HI/AH/VH,
No Social Issues, No Memory Changes, No Violence/Abuse Hx., No Eating Concerns
Heme/Lymph: No Bruising, No Bleeding, No Transfusions History, No Lymphadenopathy
Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance

ER Course:
Vital signs:
Labs significant for:
Imaging
Pt was given

Physical Exam:
Vitals: T(C): Max:
BP:
HR:
RR:
SpO2:
General Appearance: Well developed, well nourished, alert and cooperative, and appears to be
in no acute distress.
Head: Atraumatic, normocephalic.
Eyes: PERRL, EOMI. Fundi normal, vision is grossly intact.
Ears: External auditory canals and tympanic membranes clear, hearing grossly intact.
Nose: No nasal discharge.
Throat: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth
and gingiva in good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
Cardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral
edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2
seconds. No carotid bruits.
Lungs: Clear to auscultation and percussion without rales, rhonchi, or diminished breath
sounds.
Abdomen: No masses Hyperactive bowl sounds in all four quadrants. Diffusely tender to light
palpation. (+) Abdominal guarding. (-) Murphy’s sign.
MSK: Adequately aligned spine. ROM intact spine and extremities. No joint thema or
tenderness. Normal muscular development. Normal gait.
Extremities: No significant deformity or joint abnormality. Peripheral pulses intact. No
varicosities. Normal range of motion, normal sensation with distal capillary filling of less than 2
seconds without tenderness, discoloration, nodules, weakness or deformity. No edema.
Neurological: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes
2+ throughout. Cerebellar testing normal.
Skin: Skin normal color, texture and turgor with no lesions or eruptions. No rashes.

Labs and Results:

Assessment and Plan:

____ yo male with PMHx significant for ___ and hyperlipidemia, presents to the hospital
for_____ _____ days prior to admission. Exam significant for _____ . Labs significant for ______
and imaging is _______.

#1
- DDx:
- Explain
- Plan

#2 Acidosis

·
#5 DVT Prophylaxis

Diet regular as tolerated. NPO after midnight

Tauhid Mahmud, MS4

Discussed with