MEDICINE ADMISSION NOTE
SOURCE AND RELIABILITY OF HX
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
Identifiers: NAME is a AGE year old SEX with a history of *** who presents from *** to *** with *** lasting *** in the setting of ***
HPI explained by patient:
Pertinent patient history:
Pertinent ROS:
Pertinent physical exam findings:
ED/ICU course:
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
ALLERGIES
MEDICATIONS PRIOR TO ADMISSION
SUBSTANCE USE
SEXUAL HISTORY
SOCIAL HISTORY
FAMILY HISTORY
REVIEW OF SYSTEMS
General: patient denies fevers, chills, sweats, weakness, fatigue, weight changes, difficulty sleeping, or changes in appetite.
Dermatological: patient denies any rashes, lumps, sores, itchiness, dryness, color changes, nail changes, hair changes, easy bruising, or bleeding.
Head: patient denies headaches, dizziness, light headedness, or issues with syncope.
Eyes: patient does not use any visual aids. Patient denies vision changes, blurriness, diplopia, visual field deficits or seeing spots, flashing lights, or halos around lights.
Ears: patines does not use hearing aids. Patient denies difficulty hearing, pain in the ears, discharge, buzzing, or ringing of ears.
Nose: patient denies runny nose, hay fever, nose bleeds, or sinus infections.
Mouth: patient visits dentist regularly. Denies pain in the mouth, bleeding gums, trouble chewing food, or swelling of mouth/face/lip.
Throat: patient denies any pain in their throat, hoarseness, voice changes, or trouble swallowing.
Neck: patines denies any swollen glands or lumps in the neck. Denies stiffens or pain in the neck.
VITAL SIGNS
INTAKE/OUTAKE
I/O(24hours):
Net I/O:
PHYSICAL EXAM
General: well appearing and comfortable.
Mental status exam: alert and orientated X3
HEENT:
- Head: normocephalic and atraumatic. No tenderness upon sinus palpation.
- Eyes: no evidence of inflammation, infection, or trauma upon external inspection. No scleral icterus.
- Ears: no evidence of inflammation, infection, or trauma upon external inspection.
- Nose: no evidence of inflammation, infection, or trauma upon external inspection.
- Throat: oral music pink with no evidence of no evidence of inflammation, infection, or trauma upon external inspection. Good dentition with all teeth present and white in color. No halitosis.
- Neck: supple. No supraclavicular, submandibular, submental, preauricular, postauricular, or cervical lymphadenopathy. Unable to palpate thyroid. The trachea is in the midline.
Cardiovascular: mucous membranes moist. No jugular venous distention. S1 and S2 heard with no murmurs, rubs, or gallops.
Cranial nerves: CNI- CNXII intact
- CNI: Patient denies issues with olfaction
- CNII: Pupils X mm in size and equally round bilaterally.Pupils reactive to light with intact direct and consensual responses bilaterally. Visual fields intact bilaterally.
- CNIII, IV, and VI: ocular movements preserved bilaterally. No ptosis or nystagmus observed.
- CNV: pinprick and light touch sensation preserved bilaterally in the ophthalmic, maxillary, and mandibular branches of the trigeminal nerve.
- CNVII: no facial asymmetry observed when patient raises eyebrows, squints, or smiles.
- CN VIII: patient able to hear finger rub bilaterally. Acuity good to conversation.
- CN IX, X: palate symmetrical. No uvula deviation.
- CN XII: tongue symmetrical with no atrophy or deviation.
- CN XI: patient able to shrug shoulders and turn head bilaterally.
LABS
IMAGING
ASSESSMENT AND PLAN
NAME is a AGE year old SEX with a history of *** who presents from *** to *** with *** lasting *** in the setting of *** found to have ***, concerning for ***. Patient has the following medical issues which require the associated interventions:
- Problem #1
- Intervention #1
- Intervention #2
- Intervention #3
- Problem #2
- Intervention #1
- Intervention #2
- Intervention #3
- Problem #3
- Intervention #1
- Intervention #2
- Intervention #3
Mr. Stepwards, MSIII
DATE
Pager: XXXX