Sample History and Physical Note
Charting Plus™ - Electronic Medical Records
Note for Jane Doe on 4/10/02 - Chart 5407
CHIEF COMPLAINT (1/1): This 32 year-old female prents today for an initial obstetrical examination.
Home pregnancy test was positive.
The patient indicates fetal activity is not yet detected (due to early stage of pregnancy).
LMP: 02/13/2002 EDD: 11/20/2002 GW: 8.0 weeks.
Patient has been trying to conceive for 6 months.
Mens: Ont: 12 years old. Interval: 24-26 days. Duration: 4-6 days. Flow: moderate.
Complications: PMS - mild.
Last Pap smear taken on 11/2/2001.
Contraception: Patient is currently using none.
Allergies: Patient admits allergies to venom - bee/wasp resulting in difficulty breathing, vere rash, pet dander resulting in nasal stuffiness.
Medication History: None.
Past Medical History: Past medical history is unremarkable.
Past Surgical History: Patient admits past surgical history of tonsillectomy in 1980.
Social History: Patient admits alcohol u Drinking is described as social, Patient denies illegal drug u, Patient denies STD history, Patient denies tobacco u.
Family History: Patient admits a family history of cancer of breast associated with mother.
Review of Systems: Neurological: (+) unremarkable, Respiratory: (+) difficulty sleeping, (-) breathing difficulties, respiratory symptoms, Psychiatric: (+) anxious feelings, Cardiovascular: (-) cardiovascular problems or chest symptoms, Genitourinary: (-) decread libido, (-) vaginal dryness, (-) vaginal bleeding.
Diet is high in empty calories, high in fats and low in fiber.
Physical Exam: BP Standing: 126/84 Resp: 22 HR: 78 Temp: 99.1 Height: 5 ft. 6 in. Weight: 132 lbs.
Pre-Gravid Weight is 125 lbs.
Patient is a 32 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.
Oriented to person, place and time.
Mood and affect normal and appropriate to situation.
HEENT:Head & Face: Examination of head and face is unremarkable
Skin: No skin rash, subcutaneous nodules, lesions or ulcers obrved.
No edema obrved.
Cardiovascular: Heart auscultation reveals no murmurs, gallop, rubs or clicks.
Respiratory: Lungs CTA.
Breast: Che st (Breasts): Breast inspection and palpation shows no abnormal findings
Abdomen: Abdomen soft, nontender, bowel sounds prent x 4 without palpable mass.
Genitourinary: External genitalia are normal in appearance.
Examination of urethra shows no abnormalities.
Examination of vaginal vault reveals no abnormalities.
Cervix shows no pathology.
征的组词
Uterine portion of bimanual exam reveals contour normal, shape regular and size normal.
Adnexa and parametria show no mass, tenderness, organomegaly or nodularity.
Examination of anus and perineum shows no abnormalities.
Test Results: Urine pregnancy test: positive.
CBC results within normal limits.
写日记200字Blood type: O positive.
Rh: positive.
FBS: 88 mg/dl.
Impression: Pregnancy, normal first.
Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets. Plan: Pap smear submitted for manual screening.
Ordered CBC.
Ordered blood type.
Ordered hemoglobin.
Ordered Rh.
Ordered fasting blood gluco.
Counling: Counling was given regarding adver effects of alcohol, physical activity and xual activity.
Educational supplies dispend to patient.
Return to clinic in 4 week(s).
Prescriptions:
Natalcare Plus Dosage: Prenatal Multivitamins tablet Sig: QD Dispen: 60 Refills: 4 Allow Generic: Yes Patient Instructions:
Patient received written information regarding pre-eclampsia and eclampsia.
Patient was instructed to restrict activity.
Patient instructed to limit caffeine u.
Patient instructed to limit salt intake.
_______________________________ A. Obstetrician-Gynecologist, MD
Sample Referral Letter
Charting Plus™ - Electronic Medical Records
4/10/02
Marcus Welby, MD
最大的数量单位1231 8t h Street, Suite 222
West Des Moines, IA 50265
Dear Dr. Welby:
Jane Doe was en in my office in consultation as requested by you as a new patient for evaluation and care. The following is a summary of my findings and recommendations:
Impression: Pregnancy, normal first.
电脑锁屏设置Maternal nutrition is inadequate for protein and poor and high in empty calories and junk foods and sweets. Plan: Pap smear submitted for manual screening.
Ordered CBC.
Ordered blood type.
Ordered hemoglobin.
Ordered Rh.
Ordered fasting blood gluco.
Counling: Counling was received regarding adver effects of alcohol, physical activity and xual activity. Educational supplies dispend to patient.
Return to clinic in 4 week(s).
Prescriptions:
Natalcare Plus Dosage: Prenatal Multivitamins tablet Sig: QD Dispen: 60 Refills: 4 Allow Generic: Yes Patient Instructions:
Patient received written information regarding pre-eclampsia and eclampsia.
Patient was instructed to restrict activity.
Patient instructed to limit caffeine u.
Patient instructed to limit salt intake.
If I may be of any further assistance in the care of your patient, plea let me know. Thank you for providing me the opportunity to participate in the care of your patients.
Sincerely,
A. Obstetrician-Gynecologist, MD
Sample Patient Instructions
Charting Plus™ - Electronic Medical Records
Patient Instructions for Jane Doe on 04/10/2002
PRE-ECLAMPSIA AND ECLAMPSIA
What is it?
Pre-eclampsia is a very rious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromid. It usually occurs from the 20th week of pregnancy to 7 days postpartum. The cau is unknown. It is also known as pregnancy-induced hypertension or toxemia of pregnancy. Eclampsia is the end-stage of the pre-eclampsia process. The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years. There are identifiable risk factors for developing pre-eclampsia: family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy). A chronic high blood pressure and underlying blood vesl dia increas the risk.
Pre-eclampsia ranges from mild to vere to eclampsia as the end-stage. Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.
Signs and symptoms:
Mild pre-eclampsia:法制小知识
* Significant blood pressure increa even if you are still within the normal blood pressure limits.
* Swelling in the face, hands and feet which worns in
* Gaining more than a pound a week, especially in the last trimester.
* Routine prenatal checkup reveals protein in the urine.
* Seizures are possible.
Severe pre-eclampsia:
* More blood pressure increa.
* Further swelling in face, hands and feet.
* Visual disturbances.
* Headache.
* Irritability.
* Abdominal pain.
* Tiredness.
* Decread urination.
* Seizures possible.
* Naua and vomiting.
Eclampsia:
* Symptoms worn.
* Seizures.
* Muscle twitches.
* Coma.
Treatment:
* Diagnosis - blood tests, urinalysis, blood pressure monitoring.
* Mild preeclampsia can be treated at home. Severe symptoms require hospitalization and possible
early delivery of the baby, often by cesarean ction.
* Daily weighing.
* Daily monitoring for protein in urine.
* Medications to lower blood pressure if preeclampsia is vere.
* Magnesium sulfate or other anti-izure drugs may be necessary to prevent izures.
* Get lots of rest! Lay on your left side to help circulation.
* Follow any dietary advice given by your doctor.
* Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.
* Never take any medications that are not prescribed or recommended by your physician.
Call the office if your headaches become vere, you have visual disturbances or if you gain more than 3 pounds in 24 hours.
RESTRICTING ACTIVITY
( ) You should significantly restrict activities.
( ) Your activities should be slightly restricted.
( ) You may go about your normal daily routines.
( ) You should not go to work.
( ) You may work with restrictions.爱迪生发明了什么
( ) You may work without restrictions.
RESTRICTING CAFFEINE:
You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda. In addition, you should avoid chocolate that also contains caffeine.
RESTRICTING SALT:
秋兴陆游You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration. For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.
北堤麻辣肉_______________________________A. Obstetrician-Gynecologist, MD
