PARM MAVI

INTERNAL MEDICINE CLERKSHIP ADMISSION H&P

CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS
REVIEW OF SYSTEMS
General: positive for fatigue !ea"#ess, no weigh gain!weigh lo"", no #e$er", %hill"
S&in: no ra"h, 'r(ri(" or new le"ion"
Hea): no hea)a%he", hea) %on("ion" or *r(i"ing
E+e: no *l(rre) or )o(*le $i"ion, no e+e 'ain
ENT!Mo(h: positive for $%ee&i#g gu's, no e'i"a,i", no na"al or "in(" %onge"ion, no "ore
hroa
Re"'iraor+: positive for s(ort#ess of $reat(, no whee-ing, no %o(gh or "'((. 'ro)(%ion
Car)io$a"%(lar: positive for )(est pai# a#& %eg s!e%%i#g, no 'al'iaion", no orho'nea, no
PND, no %la()i%aion
Ga"roine"inal: positive for rig(t*si&e& a$&o'i#a% pai# re)ta% $%ee&i#g, no na("ea,
$o.iing, )iarrhea, no re*o(n) en)erne"" or g(ar)ing
Genio(rinar+: no )+"(ria, no (rinar+ #re/(en%+ or (rgen%+
M("%(lo"&eleal: no .("%le a%he", no 0oin 'ain, no *a%& 'ain
He.aologi%!L+.'hai%: positive for eas+ $ruisi#g,$%ee&i#g, no l+.'ha)eno'ah+
En)o%rine: no hea!%ol) inoleran%e, no 'ol+)i'"ia, no 'ol+(ria
Ne(rologi%: positive for !ea"#ess, no )i--ine"" or %on#("ion, no n(.*ne"" or ingling, no
"+n%o'e
P"+%hologi%al: no an,ie+ or )e're""ion, no .e.or+ lo"" or in"o.nia
ME-ICATIONS
ALLER.IES
PAST ME-ICAL HISTORY
PAST S/R.ICAL HISTORY
FAMILY HISTORY
SOCIAL HISTORY
PHYSICAL E0AMINATION
General a''earan%e: aler, %oo'erai$e, in no a%(e )i"re"" an) well1no(ri"he)
Vial "ign": 2345
o
67 HR 887 RR 9:7 ;P 5<9!297 S'O9 2<=
S&in: S&in %olor, e,(re an) (rgor nor.al7 no ra"he" or "&in le"ion"
Hea): Nor.o%e'hali%, wiho( o*$io(" a*nor.ali+, ara(.ai%
E+e": Con0(n%i$ae %lear, '('il" e/(all+ ro(n) an) rea%i$e o ligh an) a%%o..o)aion, e,ra1
o%(lar .o$e.en" ina%
Ear": T+.'ani% .e.*rane" 'earl+ wih nor.al ear %anal" in *oh ear"
No"e: Nare" nor.al7 "e'(. .i)line7 .(%o"a nor.al7 no )rainage or "in(" en)erne""
Mo(h: Li'", .(%o"a, an) ong(e nor.al7 eeh an) g(." nor.al, no *lee)ing noe) #ro. g(."
Ne%&: No %aroi) *r(i, no >VD, ra%hea .i)line, no h+ro.egal+, no en)erne""!.a""!no)(le"
L+.'h: No %er$i%al, "('ra%la$i%(lar an) a,illar+ no)e" noe)
;rea"": De#erre)
Re"'iraor+: Clear o a("%(laion *ilaerall+, goo) air .o$e.en hro(gho(7 no whee-e" or
%ra%&le"
Car)io$a"%(lar: ;ra)+%ar)ia ?89*'.@7 gra)e A!< earl+ )ia"oli% .(r.(r hear) *e" a he righ
(''er "ernal *or)er
A*)o.en: .il)1.o)erae en)erne"" o 'al'aion on righ "i)e o# a*)o.en7 no re*o(n)
en)erne"" or g(ar)ing
Genial!Pel$i%: De#erre)
Re%al: De#erre)
E,re.iie": AB non1 'iing e)e.a o# he lower e,re.iie" *ilaerall+, 5B )i"al '(l"e"
M("%(lo"&eleal: C!C "rengh hro(gho(
Ne(rologi%: Cranial ner$e" gro""l+ ina%7 DTR" no e"e)
ME-ICAL -ATA
Renal
o So)i(.:
o Poa""i(.:
o Chlori)e:
o Ser(. CO9:
o ;DN:
o Creainine:
o Gl(%o"e:
o Cal%i(.:
o Pho"'hor(":
o Magne"i(.:
He'ai%
o Al&aline 'ho"'haa"e:
o AST:
o ALT
o Al*(.in:
o Toal "er(. 'roein:
o Toal "er(. *ilir(*in:
o Li'a"e:
Car)ia%
o Car)ia% ro'onin:
o ;NP:
C;C
o E;C:
o R;C:
o He.oglo*in:
o He.ao%ri:
o MCV:
o RDE:
o Plaele":
Di##erenial
o Ne(ro'hil" ?relai$e@:
o L+.'ho%+e" ?relai$e@:
o Mono%+e" ?relai$e@:
o Eo"ino'hil" ?relai$e@:
o ;a"o'hil" ?relai$e@:
o Ne(ro'hil" ?a*"ol(e@:
o L+.'ho%+e" ?a*"ol(e@:
o Mono%+e" ?a*"ol(e@:
o Eo"ino'hil" ?a*"ol(e@:
o ;a"o'hil" ?a*"ol(e@:
Proi.e!INR
o Proi.e :
o INR:
Drinal+"i"
o Clari+:
o Color:
o 'H:
o S'e%i#i% gra$i+:
o Proein:
o Gl(%o"e:
o Keone":
o ;ilir(*in:
o ;loo):
o Nirie:
o Dro*ilinogen:
o Le(&o%+e":
o R;C:
o E;C:
o ;a%eria:
o H+aline %a"":
Drine Che.i"r+
o Chlori)e:
o Creainine:
o Poa""i(.:
o So)i(.:
Sool e""
IMA.IN.
ASSESSMENT
PLAN 1Y PRO1LEMS