Medicine Admit, Progress, D/C
Admission HPI
HPI
SUBJECTIVE
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CC: _
HPI: _
REVIEW of SYSTEMS:
Constitutional: _no symptoms.
Eyes: _no symptoms.
Ears/Nose/Mouth/Throat: _no symptoms.
Cardiovascular: _no symptoms.
Respiratory: _no symptoms.
Gastrointestinal: _no symptoms.
Genitourinary: _no symptoms.
Musculoskeletal: _no symptoms.
Integumentary (skin/breast): _no symptoms.
Neurological: _no symptoms.
Psychiatric: _no symptoms.
Endocrine: _no symptoms.
Hematologic/Lymphatic: _no symptoms.
Allergic/Immunologic: _no symptoms.
PAST HISTORY
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MEDICAL HISTORY:
_
OB/GYN HISTORY:
_
SURGICAL HISTORY:
_
SOCIAL HISTORY:
_
FAMILY HISTORY:
_
ALLERGIES:
_NKDA
CURRENT MEDICATIONS:
_
ER COURSE
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_
OBJECTIVE
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Vitals (initial ER): HR _, BP _, R _, T _F, SPO2 _% on RA, _/10 pain
Vitals (repeat ER): HR _, BP _, R _, T _F, SPO2 _% on RA, _/10 pain
PHYSICAL EXAM:
GEN: _
PSY: _AAO. Normal affect. Appropriate insight during interview.
NEURO: _Grossly intact.
EYE: _Normal conjunctiva, normal lids. PERRL, normal iris.
ENT: _Moist mucous membranes. Normal external appearance of ears, nose.
NECK: _Normal appearance.
LYMPH: _No cervical lymphadenopathy. No extremity lymphadenopathy.
CARD: _S1, S2 RRR no M/R/G.
LUNG: _CTAB no W/R/R. Normal resp effort.
ABD: _Soft, NT, ND, NABS. No HSM.
SKIN: _Skin warm and dry without rash or lesions.
EXT: _No CCE.
EKG: _
LABS: _
RADS: _
ASSESSMENT & PLAN
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_
Problem 1
_
Problem 2
_
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ICU Progress Note
24 Hour Events
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_
SUBJECTIVE
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_
OBJECTIVE
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VITALS:
HR _
Tele _
SBP _
DBP _
MAP _
T _
RR _
O2 _
Vent _
I: _ ml
_ PO
_ IV
_ IV Meds
O: _ ml
_ Urine
Stool x _
I/O Net = _ ml
PHYSICAL EXAM
GEN: _
PSY: _AAO. Normal affect. Appropriate insight during interview.
NEURO: _Grossly intact.
EYE: _Normal conjunctiva, normal lids. PERRL, normal iris.
ENT: _Moist mucous membranes. Normal external appearance of ears, nose.
NECK: _Normal appearance.
LYMPH: _No cervical lymphadenopathy. No extremity lymphadenopathy.
CARD: _S1, S2 RRR no M/R/G.
LUNG: _CTAB no W/R/R. Normal resp effort.
ABD: _Soft, NT, ND, NABS. No HSM.
SKIN: _Skin warm and dry without rash or lesions.
EXT: _No CCE.
EKG/TELE:
_
LABS:
_
RADS:
_
ASSESSMENT & PLAN
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_Impression
# CARDIO
-- _
# PULM
-- _
# GI
-- _
# FEN/Renal
-- _
# ENDO
-- _
# HEME
-- _
# ID
-- _
# INTEGU
-- _
# NEURO/PSYCH
-- _
# PROPHY DVT/GI
-- _
# SOCIAL/DISPO
-- _
-- Family point of contact (name, relation, number/email): _
# CODE
-- _
--- FAST HUGS BID ---
Feeding
Analgesia
Sedation
Thrombus
Head of Bed
Ulcer, prophylaxis
Glycemic
Spont breathing
Bowel
Indwelling
De-Escalation
Discharge Summary
DISCHARGE SUMMARY
DIAGNOSES AT DISCHARGE
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_
REASON FOR ADMISSION
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_
HOSPITAL COURSE
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_
--- Physical Exam on Discharge ---
_
--- Labs on Discharge ---
_
--- Rads during hospitalization ---
_
DISCHARGE MEDICATIONS
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_
TRANSFER INSTRUCTIONS
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_
CONDITION ON DISCHARGE
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_