Example of a Complete History and Physical Write-up
Patient Name:
Unit No:
钉纽扣Location:
阳台上
Informant: patient, who is reliable, and old CPMC chart.
Chief Complaint: This is the 3rd CPMC admission for this 83 year old woman with a long history of hypertension who prented with the chief complaint of substernal “toothache like” chest pain of 12 hours duration.
History of Prent Illness: Ms J. K. is an 83 year old retired nur with a long history of hypertension that was previously well controlled on diuretic therapy. She was first admitted to CPMC in 1995 when she prented with a complaint of intermittent midsternal chest pain. Her electrocardiogram at that time showed first degree atrioventricular block, and a chest X-ray showed mild pulmonary congestion, with cardiomegaly. Myocardial infarction was ruled out by the lack of electrocardiographic and cardiac enzyme abnormalities. Patient was discharged after a brief stay on a regimen of enalapril, and lasix, a
nd digoxin, for presumed congestive heart failure. Since then she has been followed cloly by her cardiologist.
Aside from hypertension and her postmenopausal state, the patient denies other coronary artery dia risk factors, such as diabetes, cigarette smoking, hypercholesterolemia or family history for heart dia. Since her previous admission, she describes a stable two pillow orthopnea, dyspnea on exertion after walking two blocks, and a mild chronic ankle edema which is wor on prolonged standing. She denies syncope, paroxysmal nocturnal dyspnea, or recent chest pains.
She was well until 11pm on the night prior to admission when she noted the ont of “aching pain under her breast bone” while sitting, watching television. The pain was described as “heavy” and “toothache” like. It was not noted to radiate, nor increa with exertion. She denied naua, vomiting, diaphoresis, palpitations, dizziness, or loss of consciousness. She took 2 tablespoon of antacid without relief, but did manage to fall sleep. In the morning she awoke free of pain, however upon walking to the bathroom, the pain returned with incread verity. At this time she called her daughter, who gave her an aspirin and brought her immediately to the emergency room. Her electrocardiogram on prentation showed sinus tachycardia at 110, with marked ST elevation in leads I, AVL, V4-V6 and occasional ventricular paroxysmal contractions. Patient immediately receiv
ed thrombolytic therapy and cardiac medications, and was transferred to the intensive care unit.
Current Regimen
Digoxin 0.125mg once daily
Enalapril 20mg twice daily
Lasix 40mg once every other day
Kcl 20mg once daily
Tylenol 2 tabs twice daily as needed for arthritis
Past Health
General: Relatively good
Infectious Dias: Usual childhood illness. No history of rheumatic fever.
Immunizations: Flu vaccine yearly. Pneumovax 1996
Allergic to Penicillin-developed a diffu rash after an injection 20 years ago.
Transfusions: 4 units received in 1980 for GI hemorrhage, transfusion complicated
by Hepatitis B infection.
Hospitalizations, Operations, Injuries:
吸引近义词1) Normal childbirth 48 years ago
2) 1980 Gastrointestinal hemorrhage, e below
3) 9/1995 chest pain- e history of prent illlness
4) Last mammogram 1994, Flexible Sigmoidoscopy 1997
Systems Review
1.Constitutional: energy level generally good, weight is stable at 160 lbs, height 5’8”
2.HEENT:
headaches
No
Eyes: wears reading glass but thinks vision getting is wor, no diplopia or
eye pain
Ears: hearing loss for many years, wears hearing aid now
No: no epistaxis or obstruction
No history of tonsillitis or tonsillectomy
Wears full t of dentures for more than 20 years, works well.
3.Respiratory: No history of pleurisy, cough, wheezing, asthma, hemoptysis,
pulmonary emboli, pneumonia, TB or TB exposure
4.Cardiac: See HPI
ge开头的成语
5.Vascular: No history of claudication, gangrene, deep vein thrombosis, aneurysm.
Has chronic venous stasis skin changes for many years
6.G.I.: Admitted to CPMC in 1980 after two days of melena and hematemesis.
Upper G.I. ries was negative but endoscopy showed evidence of gastritis,
presumed to be caud by ibuprofen intake. Her hematocrit was 24% on admission and she
received four units of packed cells. Colonoscopy revealed
multiple diverticuli. Since then her stool has been brown and
consistently hematest negative when checked in clinic. Several months after
this admission she was noted to be mildly jaundiced and had elevated liver
enzymes, at this time it was realized that she contracted hepatitis B from the
transfusions. Since then she has not had any evidence of chronic hepatitis.
7.GU: History of veral episodes of cystitis, most recently E Coli 3/1/90, treated with
Bactrim. Reports dysuria in the 3 days prior to hospitalization. No fever, no
hematuria. No history of xually transmitted dia. Menarche was at 15,
menstrual cycles were regular interval and duration, menopau occurred at 54.
Seven pregnancies with 5 normal births and 2 miscarriages.
8. Neuromuscular: Osteoarthritis of the both knees, shoulder, and hips for more than
20 years. Took ibruprofen until 1980, has taken acetaminophen since her GI
bleed, with good relief of intermittent arthritis pain.
There is no history of izures, stroke, syncope, memory changes.
9. Emotional: Denies history of depression, anxiety.
10. Hematological: no known blood or clotting disorders.
11. Rheumatic: no history of gout, rheumatic arthritis, or lupus.
12. Endocrine: no know diabetes or thyroid dia.
13. Dermatological: no new rashes or pruitis.
Personal History
古代朴素唯物主义1. Mrs. Johnson is widowed and lives with one of her daughters.
2. Occupation: she worked as a nur to age 67, is now retired.
3. Habits: No cigarettes or alcohol. Does not follow any special diet.
4. Born in South Carolina, came to New York in 1931. she has never been outside of the United States.
5. Prent environment: lives in a one bedroom apartment on the third floor of a building with and elevator. She has a home helper who comes 3 hours a day.
6. Financial: Receives social curity and Medicare, and is supported by her children.
7. Psychosocial: The patient is generally an alert and active woman despite her arthritic symptoms. She understands that she is having a “heart attack” at the prent time and she appears to be extremely anxious.
Family History
The patient was brought up by an aunt; her mother died at the age of 36 from kidney failure; her father died at the age of 41 in a car accident. Her husband died 9 years ago of izures and pneumonia. She had one sister who died in childbirth.
She has 4 daughters (ages 60, 65, 56, 48) who are all healthy, and had a son who died at the age of 2 from童年趣事作文结尾
pneumonia. She has 12 grandchildren, 6 great grandchildren and 4 great, great grandchildren.
There is no known family history of hypertension, diabetes, or cancer.
Physical Exam
1. Vital Signs: temperature 100.2 Pul 96 regular with occasional extra beat, respiration 24, blood
pressure 180/100 lying down
2. Generally a well developed, slightly obe, elderly black woman sitting up in bed, breathing with slight
difficulty. She complains of resolving chest pain.
3. HEENT:
Eyes: extraocular motions full, gross visual fields full to confrontation, conjunctiva clear. sclerae
non-icteric, pulpils equal round and reactive to light and
accomodation, fundi not well visualized due to possible prence of cataracts.
Ears: Hearing very poor bilaterally. Tympanic membrane landmarks well
visualized.
No: No discharge, no obstruction, ptum not deviated.
Mouth: Complete t of upper and lower dentures. Pharynx not injected, no
exudates. Uvula moves up in midline. Normal gag reflex.
4. Neck: jugular venous pressure 8cm, thyroid not palpable. No mass.
5. Nodes: No adenopathy
6. Chest: Breasts: atrophic and symmetric, nontender, no mass or discharges. Lungs: bibasilar
rales. No dullness to percussion. Diaphragm moves
No rhonchi, wheezes or rubs.
respiration.
with
well
7. Heart: PMI at the 6th ICS, 1 cm lateral to MCL. No heaves or thrills. Regular rhythm
with occasional extra beat. Normal S1, S2 narrowly split; positive S4 gallop. A
筷子的英文
grade II/VI systolic ejection murmur is heard at the left upper sternal border
without radiation. Puls are notable for sharp carotid upstrokes.
Puls: Carotid brachial radial femoral DP PT
R 2+ 2+ 2+ 2+ 1+ 0
L 2+ 2+ 2+ 2+ 1+ 0
8. Spine: mild kyphosis, mobile, nontender, no costovertebral tenderness
9. Abdomen: soft, flat, bowel sounds prent, no bruits. Nontender to palpation.
Liver edge, spleen, kidney not felt. No mass. Liver span 10cm by percussion.
10. Extremities: skin warm and smooth except for chronic venous stasis changes in
both legs. 1+ edema to the knees, non-pitting and very tender to palpation.
No clubbing nor cyanosis.
11.Neurological: Awake, alert and fully oriented. Cranial nerves III-XII intact except
for decread hearing. Motor: Strength not tested, patient moves all extremities.
Sensory: Grossly normal to touch and pin prick. Cerebellar: no tremor nor
dysmetria. Reflexes symmetrical 1+ through out, no Babinski sign.
12. Pelvic: deferred until patient more stable.
13. Rectal: Prominent external hemorrhoids. No mass felt. Stool brown, negative for
blood
Labs
WBC 12,400 Hgb 12.0 Hct 38.0 MCV 80.0 Plts 218,000 Retic 1.3 Diff Na 143 K4.1 C1 103 CO229 Glu 102 BUN 9 Creat 0.8; T bili 0.5 Dbili 0.1
Alk Phos 155 AST 55 ALT 26 LDH 274 CPK 480, MB fraction positive,
Troponin25
U/A Sp Gr 1.008 pH 6.5 2+ Alb many WBC many RBC 3+ bact
ABG pH 7.46 pCO234 PO284 O2Sat 98% (room air) EKG NSR 96, ST elevations I, AVL, V4-V6; rare unifocal VPC’s
CXR portable AP, probable cardiomegaly, mild PVC
(*Note: In the Physical Diagnosis Cour the labs will not generally be a part of the
write-ups, as the chart is not usually available to the students)
荸荠的功效与作用Formulation
This 83 year old woman with a history of congestive heart failure, and coronary
artery dia risk factors of hypertension and post-menopausal state prents with
substernal chest pain. On exam she was found to be in sinus tachycardia, with
no JVD, but there are bibasilar rales and pedal edema, suggestive of some degree
of congestive heart failure. There were EKG changes indicate an acute
anterolateral myocardial infarction, and the labs shows elevation of CPK and
troponin.
Impression
1. Acute antelorateral myocardioal infarction, complicated by mild left
ventricular dysfunction. Patient has received thrombolysis therapy.
2. Hypertension
3. Dysuria - 3+ bacteria in urine with pyuria
Plan
1.Continue aspirin, heparin, nitrates, beta blockers, nasal oxygen. Follow
rial physical exams, EKGs, and labs.
2. Obtain echocardiogram to asss post MI heart function and murmurs heard
on cardiac exam. If LV ejection fraction is prerved, to start early beta
blocker therapy.
3. Continue ACE inhibitor therapy, and monitor blood pressure.
4. Dysuria and pyuria- probable recurrent cystitis, as she is afebrile and without costovertebral tenderness. Start Bactrim treatment for presumed uncomplicated urinary tract infection and follow up on urine culture result.
