COPD female 76 y/o at the clinic for exacerbation
Name: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats, and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and edema
Skin
Delayed healing, rashes, bruising, bleeding or skin discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, and black, tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes Neurological
Syncope, seizures, transient paralysis, weakness, paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, and cold or heat intolerance Psychiatric
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first and then brighter later.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa, pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refills two seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
Abdomen obese; BS active in all the four quadrants. Abdomen soft, nontender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Genitourinary
Bladder is nondistended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are nonpalpable.
(Male: Both testes are palpable, no masses or lesions, no hernia, and no uretheral discharge.)
(Rectal as appropriate: No evidence of hemorrhoids, fissures, bleeding, or masses—Males: Prostrate is smooth, nontender, and free from nodules, is of normal size, and sphincter tone is firm).
