Medicine notes - HISTORY I II Chief complaint at admission...

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HISTORY I. Chief complaint at admission and beyond II. HPI: 6 core questions A. Duration – longer better B. Pattern – better or worst, AM or PM, when C. Alleviating/ Provoking factors D. Associated symptoms E. What does the patient think the diagnosis is F. How can I help you? III. PMH – Is it possible you can be pregnant? IV. Medications and Allergies V. FH: HTN, diabetes, cancer, stroke, heart attack, high lipids, arterial disease VI. SH: sheltered, somebody else to care for them, occupation VII. Habits: EtOH, smoking, rec. drugs, gay/straight/bi VIII. ROS: fatigue, weight-loss/ gain PHYSICAL EXAM I. Vital signs – BP (120/80), P (60-100), Temp (abnormal is 100.5 and above), O2 sat (95% or greater), RR (12-20x), Pain scale(0/10) II. Skin: No lesion, warm, dry, color, spots III. Nodes: no cervical, axillary, supraclavicular or inguinal adenopathy, (posterior, occipital, submandibular, anterior jugular, elbow) IV. HEENT: supple, no thyromegaly or JVD. No carotid bruits, hearing, vision, teeth, runny nose, pupil equal, round, reactive to light, saliva V. Chest: clear to auscultation and percussion. Cough, shortness of breathe, chest pain VI. Breasts: symmetric with no masses or nipple discharge. Axillary tail normal VII. Cardiac: PMI (enlarged means congestive heart failure) in the mid-axillary line, 5 th ICS. No heaves. RRR (regular rate and rhythm) S1 (mitral) and 2(aortic valve); no S3 (pulmonary) or S4 (CHF). No mumurs or rubs. 1-2/6 systolic ejection murmur heard bet at the base without radiation, ending well before S2, heart pace, skip beats, fatigue with exercise VIII. Abdomen: no distension, cars or abnormal pulsations. Bowel sounds present. No masses or tenderness. (if tender, localize and identify whether there is voluntary or involuntary guarding), size, heart burn, eating, change in bowel IX. Genitourinary: normal (un)circumsized male. No testicular masses. (pelvic = refused), sexual dysfunction, urinary consinence X. Rectal – normal sphincter tone, heme negative stool, no masses or tenderness, prostate smooth without nodules XI. Extremities: no clubbing, cyanosis (not enough O2) or edema XII. Neurologic Examination: alert and oriented times 4 (person, place, time, and purpose). Cranial nerves 2-12 intact. Motor: normal tone and symmetric power. Sensory: intact to light touch. Reflexes 2+ and symmetric with down-
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going toes, any episode of loss of function or feeling, loss of vision, unconsciousness, tremors, fall VALVULAR HEART DISEASE I. Heart physical exam A. PMI – point of maximal impulse (5-6 intercoastal), no displaced 1. Location 2. Intensity B. Lifts and heaves – feel P.M.I. with hand being lifted up, say right or left, cardiomegaly (enlarged right ventricle) C. Thrills – feel P.M.I. low frequency, rumbling motion, associated with murmur. D. Palpate carotid artery – best place for pulse, upstroke
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Medicine notes - HISTORY I II Chief complaint at admission...

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