Crohns disease

GI SERVICE

CONSULT DATE	....		................
LAST NAME		FIRST NAME	. S.S #
ADMIT MD		MR#	D.O.B
CONSULTING MD		REF MD	TIME
PRIVATE MD		ADMIT DATE .

	GRQ PMH PSH ALLERGIES MEDS SH FH ROS VITALS PHYSICAL EXAM

	PROCEDURES IMAGING DISPOSITION DIAGNOSIS RECOMMENDATION GI MEDS

C.C.

AGE

Male

Female

ASA:

HPI

The patient is complaining of abdominal pain and bloody diarrhea. Patients has experienced fatigue and malaise , weight loss , and rectal bleeding . Also reports a loss of appetite. Intermittent episodes of frequent fever, bloody diarrhea, nausea, and severe abdominal cramps. No reports of problems such as arthritis, inflammation of the eye, liver disease . Reports no personal history of osteoporosis, skin rashes, anemia, and kidney stones.

The most common symptoms of ulcerative colitis are abdominal pain and bloody diarrhea. Patients also may experience Fatigue. Weight loss. Loss of appetite. Rectal bleeding. Loss of body fluids and nutrients. About half of patients have mild symptoms. Others suffer frequent fever, bloody diarrhea, nausea, and severe abdominal cramps. Ulcerative colitis may also cause problems such as arthritis, inflammation of the eye, liver disease (fatty liver, hepatitis, cirrhosis, and primary sclerosing cholangitis), osteoporosis, skin rashes, anemia, and kidney stones. No one knows for sure why problems occur outside the colon. Scientists think these complications may occur when the immune system triggers inflammation in other parts of the body. These problems are usually mild and go away when the colitis is treated.

ABDOMINAL PAIN INDEX at present? (no pain) 1 2 3 4 5 6 7 8 9 10

Nursing order Lab studies IV fluids special orders antiemetics Laxatives anit-diarrheals anti-inflammatory bowel digestive enzymes antispasmodics

	proton pump inhibitors Helicobacter h2blockers Antacids

GYNE Hx



Is the patient on Birth Control Pills?	No	YES
Is the patient on Depo-Provera?	No	YES
History of Hysterectomy?		YES
History of Tubal Ligation ?		YES
S/P Menopause		YES

Had a recent positive pregnancy test ?	No	YES
Does the patient think she is pregnant ?	No	YES
Is the patient sexually with multiple partners ?	No	YES

Hx of STD ?	No	YES
Hx of PID?	No	YES
Hx of ectopic pregnancy?	No	YES
Hx of in-vitro fertilization?	No	YES
Hx recent gynecological procedure ?	No	YES
Hx of ovarian cyst ?	No	YES
Hx of vaginal discharge?	No	YES
Watery ?		YES
foul smelling?		YES

Past Medical History


No significant past medical history
Unobtainable
hypertension	YESNO
diabetes mellitus	YESNO
asthma	YESNO
coronary artery disease	YESNO
CHF	YESNO
Myocardial Infarct	YESNO
unknown type of " heart disease "	YESNO
COPD	YESNO
chronic renal disease	YESNO
CVA	YESNO
renal dialysis	YESNO
peptic ulcer disease	YESNO
gastritis	YESNO
gastro esophageal reflux disease	YESNO
cirrhosis	YESNO
Laennec Cirrhosis	YESNO
Pancreatitis	YESNO
irritable bowel syndrome	YESNO
chronic hepatitis	YESNO
Seizures	YESNO
Migraine headaches	YESNO
chronic back pain	YESNO
Breast Cancer	YESNO
Prostate Cancer	YESNO
Colon Cancer	YESNO
Pancreatic Cancer	YESNO
Lung Cancer	YESNO
Multiple Myeloma	YESNO
Immunosuppression	YESNO
HIV (+)	YESNO
AIDS	YESNO

"cancer in the liver"	YESNO
Organic Brain Syndrome	YESNO

Past Surgical History


No hx of surgery
Unobtainable
appendectomy	YES
cholecystectomy	YES
CABG	YES
angioplasty	YES
angiogram (cardiac)	YES
heart-valve replacement	YES
hysterectomy	YES
Laparoscopy (pelvis)	YES


C-section	YES
orthopedic surgery	YES
brain surgery	YES
abdominal surgery	YES
Hernia repair	YES
Laminectomy	YES
Prostatectomy	YES
TURP	YES
Tonsillectomy	YES
Hemorrhoid resection	YES
Peripheral Vascular Surgery	YES
Mastectomy	YES	RtLt
Below Knee Amputation	YES	RtLt
Above Knee Amputation	YES	RtLt
Eye Enucleation	YES	RtLt
Cataract Surgery	YES	RtLt

renal shunt placement	YES
	-

Medications

RESPIRATORY	CARDIAC	HTN	SEIZURES/PSYCH
albuterol (Ventolin)	Lanoxin	Procardia XL	Dilantin (phenytoin)
Prednisone (tapering)	Lasix	captopril (Capoten)	carbamazepine (Tegretol)
Prednisone40mg qd	enalapril (Vasotec)	diltiazem (CalanSr)	phenobarbital
Theo-dur	Hydralazine	felodipine (Plendil)	clonazepam (Klonopin)
Serevent	Captopril	Adalat CC	clorazepate(Tranxene)
Benadryl	lisinopril	diltiazem(Tiazac)	valproic acid (Depakene)
Aerobid inhaler	ramipril	Lexxel	felbamate (Felbatol)
			topiramate (Topamax)
albuterol neb	Quinapril	Ziac	lamotrigine (Lamictal )
Prelone syrup	Bumex	amlodipine (Norvasc)	primidone(Mysoline)
Atrovent inhaler	Imdur	nisoldipine (Sular)	diazepam (Valium)
Vanceril inhaler	Nitropatch	labetalol (Normodyne)	Ativan
Allegra	Losartan	atenolol	Librium
Entex LA	Valsartan	metoprolol	Zoloft
Tussin Gel tab	Dyazide	clonidine	Prozac
Intal inhaler	HCTZ	Toprol- XL	Effexor
ANTIBIOTICS	DIABETES MELLITUS	NSAID/ ANALGESICS	MIS.
Zithromax	Glipizide	Motrin	K-lor
Biaxin	Glyburide	Naproxen	KCl
Augmentin	Rezulin	Voltaren	Axid
Keflex	Glucophage	Indocin	Tagamet
Lorabid	Acarbose	Daypro	Zantac
Doxycycline			Pepcid
Ampicillin	Insulin NPH	Relafen	omeprazole (Prilosec)
Duricef	Insulin 70/30	Lortab	Propulsid
Pen VK	Insulin Lente	Duract	antacids
erythromycin	AM DOSE	Ultram	Mylanta II
norfloxacin	PM DOSE	Lodine Xl	OTC cold MEDS
Ofloxacin		Vicoprofen	"Birth Control pills"
levofloxacin			K-Lyte
Ciprofloxacin	Insulin regular	Xanax	"water pill"
Flagyl	AM DOSE	Vicodin ES	"blood pressure meds"
Macrobid	PM DOSE	Tylenol # 3	"cannot remember names"
Bactrim	Insulin regular PRN (PPP)	Stadol inhaler	"small white pills"

	proton pump inhibitors Helicobacter therapy h2blockers Antacids

	antiemetics Laxatives anit-diarrheals anti-inflammatory bowel digestive enzymes antispasmodics

MEDICATIONS

See nurse's notes for more comprehensive "list of meds"

the patient is not taking RX medication

Allergies

*	*	*
No known allergies		*
Hx of Penicillin allergy		*
anaphylactic type response to PCN?		)
Hx of multiple drug allergies-including		)
*	*	*

Social History

Not available Noncontributory Unobtainable Significant for:
Hx of smoking exposure at home /work?	YESNO
Smoker	YESNO
If "yes" for smoking then how long ?
ETOH no use mild moderateheavy

Uses cocaine?	YESNO
Uses heroin ?	YESNO
IV drug user ?	YESNO
Quit use of IVDA?	YESNO

Sexual Preference	heterosexual homosexual
	bisexual

Work related questions
select for employment questions
enter type of employment

Disability NO YES...	The patient is disabled because of
Unemployed YES No

Family History

Not available Noncontributory Unobtainable Significant for:
DM	YES	NO	Cancer	YES	NO
HTN	YES	NO	Breast cancer	YES	NO
Asthma	YES	NO	Colon	YES	NO
Gallstones	YES	NO	pancreas	YES	NO
Migraines	YES	NO
CAD	YES	NO	Sickle Cell	YES	NO
"heart disease "	YES	NO	Thalassemia	YES	NO
Rheumatological disorders	YES	NO	Cystic Fibrosis	YES	NO

Review of Systems


GENERAL	wt loss	night sweats	malaise
	fever	weakness	"lack of strength"

Central nervous system	transient loss of vision	numbness to arm /legs	memory loss
	paresthesias	hypesthesias	anesthesias
	disturbances in smell	visual disturbances	oral facial paresthesia
	difficulty chewing	facial weakness	hearing and equilibrium
	swallowing problems	incoordination	involuntary movement s
			.
Gastrointestinal	BRBPR	change in bowel habits	melena
	dysphagia	odynophagia	reflux
	hematemesis	jaundice	hemorrhoids
	decrease in appetite	flatulence	chronic diarrhea


Respiratory	SOB with exertion	cough with sputum	wheezing
	hemoptysis	change in color of sputum	chronic cough


Cardiovascular	chest pains	PND/orthopnea	ankle swelling
	palpitations	tachycardia	dizziness
	near syncope	cyanosis	dependent edema
	exertional dyspnea	exertional chest pain	exertional diaphoresis
	cold extremities	stasis dermatitis	claudication


Renal	frequency/ urgency	blood in urine	flank pains
	incontinence	dysuria	renal colic

Musculoskeletal	joint pains	joint swelling	myalgias
	intermittent claudication	leg cramps	past clots in the veins

Urological	dribbling	decrease force of stream	penile discharge
	testicular mass	erectile dysfunction	testicular pain


Gynecological	amenorrhea	dysmenorrhea	DUB
	vaginal discharge	chronic pelvic pain	postmenopausal bleeding
	"vaginal itching"	dyspareunia	DES exposure

Breasts	lumps	breast pain	nipple discharge

Endocrine	polyuria	polydipsia	polyphagia
	heat/cold intolerance	"goiter"	excessive sweating
	change in skin pigmentation	exophthalmos	tremor


Skin	changes to moles	lesion with poor wound healing	bleeding skin lesions


ENT	hoarseness	neck masses	dysphagia
	diplopia	visual loss	eye discharge
	epistaxis	sinusitis	nasal discharge

	deafness	tinnitus	vertigo
	leukoplakia	Trush	mouth sores

all other systems negative...............'' the rest of the ROS are Unobtainable

VITALS

BP.sys	P	R	TEMP ....PULSE OX:
BPdias			WT: ............................................

Physical Exam

PHYSICAL EXAMINATION


HYDRATION	Good	adequate	Dry
GENERAL	Focused	Expanded	Detailed
EYE	Focused	Expanded	Detailed
EAR NOSE & THROAT	Focused	Expanded	Detailed
NECK	Focused	Expanded	Detailed

CARDIAC	Focused	Expanded	Detailed
LUNG	Focused	Expanded	Detailed
ABDOMINAL EXAM	Focused	Expanded	Detailed

PERIPHERAL PULSES	Focused	Expanded	Detailed
NEUROLOGICAL EXAM	Focused	Expanded	Detailed
PSYCHIATRIC	Focused	Expanded	Detailed

FEMALE EXAM	Focused	Expanded	Detailed
FEMALE EXAM	Focused	Expanded	Detailed
RECTAL EXAM	heme negative	heme positive	deferred

MUSCULOSKELETAL	Focused.	Expanded	Detailed
LYMPHATICS	Focused	Expanded	Detailed.
SKIN	Focused	Expanded	Detailed.

Working Diagnosis

Treatment

Recommendation

Nursing order Lab stuties IV fluids special orders Recommended Drug Therapy

Nursing orders	Laboratory Studies
Vitals :	CBC , platelets , PT,PTT, SMA 12 ,ECG, UA, AST, ALT, CALCIUM,
q 15 min q 2hrs q15 min until stable	CBC , platelets , PT,PTT, COMPREHENSIVE, Amylase and lipase: today and repeat in AM
q 30 min q shift (at least)	Serum Amylase and Lipase today and repeat in AM
	ABG (Stat)
Call If B/P < 90/60 , P>110 , Res > 22	Gallbladder Ultrasound (today)
	HIDA Scan (today)l
Diet :	CT (abdomen) with and without contrast IV : no oral cotrast
NPO	Obstructive Series (today)
NPO except for PO meds and ice chips
NPO except for meds	LIVER PROFILE (AST, ALT, ALP, total bili, direct , ALB, total protein)
	Gamma glutamyl / transpeptidase GT/GGT
Clear Liquid
Full liquids
Ad libitum
IV Access	RECOMMENDED SEROLOGY:
Central line access	Hepatitis Hepatitis Hepatitis Hepatitis	B C D A	Hepatitis B-RNA by PCR Hepatitis C-RNA by PCR Hepatis C Genotype
Large bore #16 angiocath X1
Large bore #16 angiocath x2

	Ceruloplasmin
	Serum Iron , TIBC and Ferritin
IV FLUIDS	Alpha-1- antitrypsin
LR 1 liter bolus .9NaCl 1 liter bolus
then start
LR .9NaCl D5w + .45 NaCl	Serum AMA
	Serum Smooth Muscle Antibody Antimytochondrial Antibody
IV RATE :	Serum Alpha fetoprotein
ml/hour or ml /minute
ACTIVITY	IgA endomysial antibodies
Bed rest Bed rest with BRP	Antigliadin antibody
	Antireticulin Antibody
	Anti liver /kidney microsomal


Daily Weights :	DIAGNOSTIC TESTS
	stool for C. difficile antigens and antibodies
Gluco scan q 8 hr	stool for LEUKOCYTE SMEAR
regular insulin (sliding scale)	stool for guaiac test x 3
Humolog insulin (sliding scale)	stool for enteric pathogens (E. Coli O157 H7, Salmonella and Shigella, campylobacter ,
	stool for Ova and parasites
	Gastric Carcinoma (CA 19-9)
	Stool for H-PYLORI



Special Procedures	Special orders
Gastric Lavage	Type and Screen
continue lavage until clear	Type and Cross for 2 units of PRBC'
discontinue lavage after 2 Liters	Give 2 units of PRBC's to run as fast as possible then give 2 additional units over 4 hours /unit
	Serial Hb/HCT's q 4 hours
EGD	Hb and HCT 1 hour post transfusion
EGD(Today) when hemodynamically stable	Hb/Hct q 2hr x 6
EGD scheduled in AM	Hb/Hct and repeat q 6 hours and in AM
	Hb/Hct and repeat q 6 hours and in AM
COLONOSCOPY
Colonoscopy in AM	GENERAL SURGERY CONSULTAION (ASAP)
Colonoscopy during hospitalization	General surgery consultation (Today )
Colonoscopy as an outpatient	General surgery consultation ( in AM )

Flexible Sigmoidoscopy	Correct coagulopathy with 2 units of FFP
No prep	Correct coagulopathy with 2 units of FFP + Vitamin K 10 mg SC
2 fleet enemas before procedure

GI MEDICATIONS

proton pump inhibitors Helicobacter h2blockers Antacids

Recommended Drug Therapy
Proton Pump Inhibitor		Helicobacter pylori therapy
omeprazole (Prilosec)		Helidac (bismuth subsalicylate + flagyl + tetracycline) 1 dose qid x 2wk + H2 blocker
20 mg 40 mg qd 40 mg BID		1 dose qid x 2wks + H2 blocker

lansoprazole (Prevacid)		Prevpac (lansoprazole + Amoxil + clarithromycin)
30 mg qd 15 mg qd		1 tab po bid X 14 days

rabeprazole (Aciphex)		Tritec (ranitidine+bismuth citrate) + Biaxin
20 mg qd		400 mg bid x 4 wks + Biaxin 500 mg po tid for 2 wk

pantoprazole (Protonix)		omeprazole +Biaxin + Amoxil x 14 days
40 mg po qd 40 mg IV qd		20 mg bid +500 md bid+ 1 gm po bid


H2 Blockers		Antacids and Miscellaneous
Cimetidine (Tagamet)		Maalox (aluminum and mag hydroxide)
400 mg BID 800 mg BID		20 ml up to 6 times /day

ranitidine (Zantac)		sucralfate (Carafate)
150 mg q12 hrs 6.25 mg IV/drip		1 gm po 1 hr. AC and qhs 1gm / 10 ml

famotidine (Pepcid)		misoprostol (Cytotec)
40 mg BID		100 mcgm PO QID

nizatidine (Axid)
300 mg qhs 150 mg qhs

antiemetics Laxatives anit-diarrheals

Antiemetics		Laxatives
prochlorperazine (Compazine)		MiraLax 17 grams PO qd
5-10mg IV 25 mg sup		PEG 4 liters for bowel prep

metoclopramide (Reglan) )		Phosphosoda
10 mg po qid 10 mg IV q2-3 hr		Mag Citrate one to two 240 ml q12 hours PRN

droperidol (Inapsine)		Sorbitol 30 cc PO QID PRN
.625 -2.5 mg IV or 2.5-10 mg IM		lactulose 30 cc PO QID PRN

tigan (trimethobenzamide)		MOM 15 to 30 mgl tid
100 mg sup tid 200 mg sup tid		Cascara 5ml PO qhs on an empty stomack
		Senna 2- 4 tabs PO qd or bid

Antiemetics		Anti-Diarrheals
phenergan		Imodium ( loperamide)
400 mg BID 800 mg BID		2mg PO per dose : Start 4 mg x 1 then 2mg po after each loose stool to a Max of 16 mg/day

ondansetron (Zofran)		Lomotil (atropine /diphenoxylate)
150 mg q12 hrs 6.25 mg IV/drip		1-2 tabs po tid/qid prn: start with 2 tabs po qid

granisetron (kytril)		Octreotide (Sandostation )
40 mg BID		50 to 100 mcg IV qday or tid (may give dose SC)

dolasetron (Anzemet)		Kaopectate (attapulgite)
300 mg qhs 150 mg qhs		750 mg /15 ml : 30 ml with each loose stool for a total of 6 dose

anti-inflammatory bowel digestive enzymes antispasmodics

Inflammatory Bowel (1)		Digestive Enzymes
mesalamine (Asacol)		Cotazym
400 mg tabs : 800 mg po tid x3-6 wks		Cotazym-S

mesalamine (Pentasa)		Creon pancrelipase
250 mg ; 1 gram po qiq x 2 months	\	10 20 5

mesalamine (Rowasa)		Pancrease MT
500 mg supp ; 4 gram/60 ml bid x 3-6 wks		10 16 20

olsalazine (Dipentum)		Donnazyme
250 mg tabs ; 500 mg bid		500 mg tabs 1 to 2 tabs with meals: donot crush

sulfasalazine (Azulfidine)		Ku-Zyme amylase/cellulase/lipase/ protease (30/2/1200/6)
500 mg tabs : 500 mg po qid		1 to 2 tabs po with meals and snack

Inflammatory Bowel (2)		Anti-spasmodics
hydrocortisone 100 mg/ 60 ml		Levsin 0.125 - 0.25 mg PO /SL qid
60 ml enema qhs x 21 days		Levsinex Timecaps .375 mg q12

Cortenema 100 mg/60 ml		Donnatal 1- 2tabs PO q6hr
60 ml enema qhs x 21 days		Donnatal Extentabs 1 tab PO q12 h

Cortifoam 10 % Rectal Foam		Pro-Banthine 15 mg PO qac and 30 mg qhs
one applicatorful qd /bid x 3 wks		propatheline generic

Entocort EC budesonide		Bentyl (dicyclomine) 40 mg qid or 20 mg IM
3 mg tabs ; 9 mg PO qam		Librax (chlordiazepoxide/clidinium)


Vancomycin 1 gm IV over 1-2 hours
Gentamicin 1.5 mg/kg IM 30 minutes before procedure

Procedure


Nasogastric tube insertion with : clear gastric content coffee ground return Bright red blood return Maroon return Refuses NG placement

NG for decompression
Central line placement	IJ Femoral Vein Subclavicular
Lumbar Puncture	performed Refuses LP
Foley-Catheter	inserted (Urine sent for U/A , C&S)
Chest tube placement	RT LT
Endotracheal intubation
Non invaside positive pressure ventilation initiated
Conscious Sedation procedure note


Orthopedic Procedures
long arm splint short arm posterior Ulnar gutter splint thumb spica short leg posterior splint Knee immobilizer shoulder immobilizer


ADDITIONAL STATEMENTS ?

CARDIAC MONITORING

ECG: Normal sinus rhythm Not clinically indicated

CARDIAC MONITORING: No evidence of ectopy Not clinically indicated (

IMAGING

CHEST-X-RAY: Normal study Not clinically indicated

ABDOMINAL SERIES : Normal study Not clinically indicated

CT(HEAD):Normal study Not clinically indicated

PLEASE ENTER OTHER STUDIES

DISPOSITION


Admit :	Medical floor .. Medical Telemetry . CCU Telemetry ICU ...Transferred to a tertiary care center Surg. floor Neurolgoy Stroke Unit 24 hr observation.................... Regular admission

Home	follow-up within 24.. . 36.... 48 hours..............5 days ..... 7 days

Nursing Home

MIS..


Old chart reviewed ?	YES	Not available

Old ECG ?	YES	Not available

Old X-rays reviewed ?	YES	Not available

Critical care given ?	YES	No

Submit

General

Demeanor

hostile argumentative anxious hyper agitated

tearful wincing chronically ill appearing very pleasant

Grooming and Personal hygiene

normal poor very poor unkempt

Body Habitus

morbid obesity obese cachectic frail thin average built

Gait and posture

normal gait staggering gait stooped old age broad based

Involuntary Movements

intention tremor dystonia athetosis oral dyskinesis

.... Other findings

Parkinsonian facies Graves disease Cushing's Moon face

ADDITIONAL STATEMENTS ?

Eyes


	Bilateral iridectomies : unable to visualize the fundus
	Bilateral cataracts : unable to visualize the fundus
	Not cooperating with eye exam : unable to visualize the fundus

	Funduscopic Examination
Right	papilledema hypertensive retinopathy normal fundus
Left	papilledema hypertensive retinopathy normal fundus


	Ocular Discharge
Right	watery mucoid purulent no discharge
Left	watery mucoid purulent no discharge

	Lumps and Swelling
Right	Sty Chalazion Dacryocystitis Episcleritis Xanthelasma
Left	Sty Chalazion Dacryocystitis Episcleritis Xanthelasma

	Conjunctival inflammation
Right	conjunctivitis iritis glaucoma subconjunctival hemorrhage

Left	conjunctivitis iritis glaucoma subconjunctival hemorrhage

	Other findings...
Right	hyphema ptosis exophthalmos periorbital edema Horner's Adie's pupil corneal abrasion Argyll Robertson pupils

Left	Other findings... hyphema ptosis exophthalmos periorbital edema Horner's Adie's pupil corneal abrasion Argyll Robertson pupils
	ADDITIONAL STATEMENTS ?

Ear

Right Eardrum

normal perforation bullous myringitis

otitis media tympanosclerosis unable to visualize

Left Eardrum

normal perforation bullous myringitis

otitis media tympanosclerosis unable to visualize

Right Pinna

normal laceration erythematous hematoma

tophi leprosy carcinoma rheumatoid nodule

Left Pinna

normal laceration erythematoushematoma

tophi leprosy carcinoma rheumatoid nodule

Right external canal

normal friable swollen pus is present

foreign body wax impacted vesicles

Left external canal

normal friable swollen pus is present

foreign body wax impacted vesicles

ADDITIONAL STATEMENTS ?

Nose

Right nostril

No nasal septum hematomano crusted blood crusted blood present

no evidence of active bleeding no polyps detected

active bleeding nasal mucosa appears swollen

polyps detected

Left nostril

No nasal septum hematomano crusted blood crusted blood

no evidence of active bleeding no polyps detected

active bleeding nasal mucosa appears swollen

polyps detected

Septum

Deviated perforated No nasal septum hematoma

Nasal Pyramid

normal depressed fracture laceration

ADDITIONAL STATEMENTS ?

Throat

TONSILS no exudates bilateral exudates diffuse mild erythema

redness and vascularity of the pillars and uvula is mild with no exudates

redness is diffuse and intense with no exudates

oral pharynx is erythematous with exudates on the tonsils with anterior cervical node enlargement

oral pharynx is erythematous with exudates on the tonsils with posterior cervical node enlargements

the throat is erythematous dull red with gray exudates over the uvula, pharynx and tongue

AIRWAY PATENCY no obstruction (wide open) appears restricted

Neck

+ Kernig and Brudzinski's sign

General

Trapezius muscle tenderness (+) More than 20 point tender spots over trapezius no trapezius muscle tenderness

Carotids

(+) right carotid bruit(+) left carotid bruit(+) bilateral carotid bruits

Thyroid Gland

diffusely enlarged multinodular goiter(RT) single nodular (LT) single nodular normal thyroid

Lymph nodes

(+) small mobile non-tender nodes small mobile non-tender nodes


	RIGHT	LEFT

Supraclavicular nodes	enlarged tender enlarged non-tender	enlarged tender enlarged non-tender
Tonsillar nodes	enlarged tender enlarged nontender	enlarged tender enlarged nontender
Submandibular nodes	enlarged tender enlarged nontender	enlarged tender enlarged nontender
Posterior auricular	enlarged tender enlarged nontender	enlarged tender enlarged nontender
Pre auricular	enlarged tender enlarged nontender	enlarged tender enlarged nontender

ADDITIONAL STATEMENTS ?

Lungs

Retractions: absent subcostal intra-costal

Adventitious sounds

bilateral expiratory wheezing localized wheezing Rt lunglocalized wheezing Lt lung

bilateral basilar rales localized basilar rales Rt lung localized basilar rales Lt lung

bilateral rhonchi localized rhonchi Rt lung localized rhonchi Lt lung

clear lungs with no adventitious sounds

Air exchange :

moving air well limited air exchange

Percussion Note

Resonant over both lung fields

dullness over the right lung base

dullness over the left lung base

hyperresonant over both lung fields CHEST WALL : With Increased AP Diameter

Tactile Fremitus And Transmitted Voice Sounds

normal bronchophony, egophony, and whispered pectoriloquy

decreased bronchophony, egophony, and whispered pectoriloquy Rt lung LFT lung

Increased bronchophony, egophony, and whispered pectoriloquy Rt lung LFT lung

obscured by wheezes (bronchophony, egophony, and whispered pectoriloquy)

Breath Sounds

normal breath sounds over all lung fields

decreased Rt lung LFT lung

Increased Rt lung LFT lung

absent Rt lung LFT lung

Trachea

Midline

deviated to the right

deviated to the left

unable to determine if deviated

Cardiac

(NO) Jugular venous distention (YES ) for jugular venous distention

PMI : normal displaced non-detected

AUSCULTATION : distant heart sounds rate and rhythm are normal irregular rhythm occasional ectopy

PALPATION : (+) parasternal lift (-) parasternal lift (+) biventricular rock (-) biventricular rock

MURMURS : No murmurs

Aortic stenosis murmur

Aortic insufficiency

Mitral regurgitation

Mitral stenosis

Grade II/VI murmur Grade III/VI murmur Grade IV/VI murmurGrade V/VI murmur Grade VI/VI murmur

S1 :normal increased sound decreased sound split

S2 :normal increased sound decreased sound split

S3 :no S3 present an S3 is present

S4 :no S4 present an S4 is present

Peripheral edema : no edema +1 edema +2 edema +3 edema +4 edema

Peripheral Vascular


	RIGHT	LEFT

Radial pulse	strongweakabsent	strongweakabsent
Ulnar pulse	strongweakabsent	strongweakabsent
Femoral pulse	strongweakabsent	strongweakabsent
Dorsalis pedis pulse	strongweakabsent	strongweakabsent
Posterior tibial	strongweakabsent	strongweakabsent

All pulses are equal bilateral and symmetrical

Unequal peripheral pulses

vascular ulcers present in the lower extremities

Pulsatile abdominal mass is present.

ADDITIONAL STATEMENTS ?

Abdominal Exam


BOWEL SOUNDS:normal absent sounds decreased bowel sounds high pitched bowel sounds
TENDERNESS :no abdominal tenderness epigastric tenderness RUQ tenderness diffuse abdominal tenderness RLQ tenderness LUQ tenderness LLQ tenderness
SIGNS :(+) Murphy's sign (+) McBurney's (+) Rovsing's (+) Psoas (+)Rt CVA(+) LT CVA no CVA tenderness (+)succussion splash (-)succussion splash Turner's Sign Cullen's
LIVER /SPLEEN:no hepatosplenomegaly enlarged nontender liver enlarged and tender liver enlarged and nodular
splenomegaly
GUARDING : there is no abdominal guarding there is diffuse abdominal guarding there is voluntary abdominal guarding
REBOUND TENDERNESS : there is no rebound there is diffuse rebound point rebound over right lower quadrant
RECTUM :heme negative heme positive refuses rectal deferred rectal rectal mass rectal tenderness
ICTERIC: YES NO
STIGMATA OF CHRONIC LIVER DISEASE Palmar erythema Dupuytren's contractures Gynecomastia Spider angiomata Ascites	NO YESNO YESNO YESNO YESNO YESNO
Other abdominal findings : (+) abdominal distention (-) abdominal distention

Genital (female)

GYNE EXAM deferred refuses pelvic exam

EXTERNAL GENITALIA

normal external genitalia normal external genitalia with no evidence of swelling of labia's

abnormality noted ..

INTROITUS normal with no excoriations or erythema erythematous with excoriations

VAGINAL VAULT no vaginal discharge Cheesy,lumpy vaginal discharge small amount of blood with no evidence of active bleeding

CERVICAL MOTION TENDERNESS

No CMT (positive ) cervical motion tenderness

ADNEXA mild bilateral adnexal tenderness moderate to severe bilateral adnexal tenderness

no bilateral adnexal tenderness

RT ADNEXA : normal with no tenderness RT with mild tenderness RT with mass and tenderness

RT marked tenderness

LT ADNEXA : normal with no tenderness LT with mild tenderness LT with mass and tenderness

LT marked tenderness

UTERUS: normal normal size but tender enlarged with irregular contour

ESTIMATED UTERINE SIZE: 8 wks 12wks 16 wks 18 wks 24wks greater than 30 wks

UTERINE POSITION ANTE-FLEXED ANTE-VERTED MIDPLANE RETRO-VERTED

RETRO-FLEXED

Genital (male)

MALE GENITAL EXAMdeferred

EXTERNAL GENITALIA

normal external genitalia

abnormality noted ..

oval dark red, painless erosion with indurated base

a cluster of small vesicles, followed by a shallow, painful , non-indurated ulcers on red bases

excrescences which are moist

indurated nodules which are not tender

phimosis is present

paraphimosis is present

penile discharge present

balanitis

SCROTUM normal Scrotal edema

RT testicle is high riding LT testicle is high riding RT testicle is tender LT testicle is tender

TESTIS no masses RT testicle is absent LT testicle is absent

RT testicle with nodule LT testicle with nodule

EPIDIDYMIS

nontender RT epididymis is tender LT epididymis is tender

HERNIA no hernias RT inguinal hernia LT inguinal hernia RT incarcerated hernia LT incarcerated hernia

FEMORAL AREA: no adenopathy RT adenopathy LT adenopathy

PROSTATE EXAM: not enlarged 2x enlargement enlarged and tender

RT lobe nodule Lt lobe nodule very hard and enlarged

Musculoskeletal

ANKLE

Sprains: Rt Lt

GRADE 1 GRADE 2 GRADE 3

KNEE :

Rt Lt

MCL sprain LCL sprain ACL damage PCL damage Medial Meniscus damage Lateral Meniscus damage effusion

HIP FX:

Rt Lt

Surgical neck Intertrochanteric Subtrochanteric

Wrist :

Rt Lt

(+) tenderness in the anatomical snuff box diffuse tenderness deQuervain's Tenosynovitis

carpal tunnel Colle's fracture deformity growth plate injury

Hand :


	RIGHT	LEFT
	Digit #	Digit #
Subungual hematoma	12345	12345
Laceration	12345	12345
Burn	12345	12345
Crush injury	12345	12345
Cellulitis	12345	12345
Paronychia	12345	12345
Tenosynovitis	12345	12345

Elbow :

Rt Lt

Nurse Maids elbow sprain ecchymosis olecranon bursitis

Forearm :

Rt Lt

distal fore-arm swelling Laceration burn partial thickness open fracture diffuse non specific soft tissue swelling

Shoulder :

Rt Lt

anterior dislocation humeral head fracture subacromial bursitis bicipital tendinitis

Clavicle :

Rt Lt

AC Separation Grade1or 2 AC Separation Grade 3 clavicle mid fx

C-SPINE :

diffuse tenderness over the trapezius muscle

point tenderness over the c-spine

ADDITIONAL STATEMENTS ?

Neurological

Alert but very confused

Restless, confused , agitated

Lethargic, distant , sleepy

ADDITIONAL STATEMENTS ?

Neurological

MENTAL STATUS : Alert, keenly responsive

Eyes are open , awake but not verbal

not alert, but easy to arouse by minor stimulation to obey, answer or respond

no alert, requires repeated stimulation to attend, or is obtunded

responds only with reflex motor or autonomic effect or totally unresponsive , flaccid, areflexic.

LEVEL OF CONSCIOUSNESS QUESTIONS (must answer the month and age)

answers questions correctly answers (1 of 2 ) question correctly

answers neither question correctly

LEVEL OF CONSCIOUSNESS COMMANDS (able to open eyes on command and grip and release

performs both tasks correctly performs one task correctly

performs neither task correctly

BEST GAZE

Unable to determine gaze abnormalities

normal

partial gaze palsy

has a gaze paresis

VISUAL FIELDS

no visual fields loss complete hemianopia

bilateral hemianopia unable to determine

LANGUAGE: no aphasia mild to moderate aphasia severe aphasia mute global aphasia

DYSARTHRIA: no dysarthria mild to moderate dysarthria severe dysarthria

intubated or other physical barrier (unable to evaluate)

CRANIAL NERVES 2-12 were intact 7 th central nerve palsy 7th peripheral nerve palsy

3,4, 6 nerve intact Rt Horner's Lt Horner's Unable to determine

LT-MOTOR

UPPER :

complete paralysis minimal effort against gravity some effort against gravity (+)drift

no drift (good motor function) unable to determine

LOWER :

complete paralysis minimal effort against gravity some effort against gravity (+)drift

(+) no drift (good motor function) unable to determine

RT-MOTOR

UPPER:

complete paralysis minimal effort against gravity some effort against gravity (+)drift

no drift (good motor function) unable to determine

LOWER:

complete paralysis minimal effort against gravity some effort against gravity (+)drift

no drift (good motor function)unable to determine

LT-SENSORY : pain touch and vibration were normal pain touch and vibration were abnormal constructional apraxia

RT-SENSORY : pain touch and vibration were normal pain touch were abnormal no constructional apraxia constructional apraxia

CEREBELLAR

RT intention tremor Lt intention tremor unable

Rt dysdiadochokinesis Lt dysdiadochokinesis

normal heel-to-shin and finger-to-nose exam

EXTINCTION AND INATTENTION

no abnormalities

mild to moderate

severe hemi-inattention

DISTAL MOTOR FUNCTION

normal

some extension

no voluntary extension

REFLEXES : plantar responses were flexor plantar responses were extensor deep tendon reflexes were symmetrical deep tendon reflexes were asymmetrical

FRONTAL LOBE RELEASING REFLEXES :

(+) Glabellar (-) Glabellar (+) Snout (-) Snout

(+) Palmar Mental (-) Palmar Mental

(+) Gegenhalten (-) Gegenhalten

Other abdominal findings : (+) Romberg no Romberg

PSYCH

Anxiety

panic attack hyperventilation stable anxiety

Depression

suicidal non suicidal decompensate dysthymic

Schizophrenia

suicidal , decompensated non suicidal decompensated

compensated agitated non agitated but dysfunctional

Psychosis