Hennepin County Medical Center

Inpatient Medicine CaRe 1

Medical Student Note
@IPHEADER@
Admitted on: @Admitdttm@
Primary care provider: @PCP@
Attending physician: @ATTPHYS@

Assessment and Plan by Problem:

@PROBHOSP@
Active Problem List:
@PROBL@
History of Present Illness:
@NAME@ is a @AGE@ @SEX@ who presents for ***
Review of Systems:

Constitutional: No fevers, night sweats, Cardiovascular: No precordial pain,

chills, myalgias or drastic changes in orthopnea or palpitations.
weight.
Gastrointestinal: No emesis,
Skin: No new worrisome lesions, heartburn, melena, No change in
rashes or ulcerations. No unexplained BM frequency or in stool
bleeding or bruising, eruptions or consistency.
pruritus.
Genitourinary: No urgency, no
Eyes: No acute changes to vision, changes in frequency, color. No
pruritus, scotomata or oculodynia. No dysuria or hematuria.
diplopia or ametropia. No
xerophthalmia. Musculoskeletal: No arthralgias or
myalgias. No recent weakness or
Ears: No changes in hearing or loss of strength.
balance; no pain, discharge,
inflammation. No tinnitus. No vertigo. Neuro/Psych: No cephalgias,
convulsions, LOC, or tremors. No
Nose/Throat/Mouth: No abnormal sudden changes in mood or
odors, changes to appetite. No feelings of self harm.
rhinorrhea, epistaxis, odynophagia,
dysphonia or ulcerations. Endocrine: No polydipsia,
polyphagia, or altered temperature
Respiratory: No SOB, DOE, tussis, sensitivity.
wheezing, or hemoptysis. No sputum
changes.
 Past Medical and Surgical History:
@PMH@
@PSH@

Social History:
@SOCHXORTHO@

Family History:
@FAMHX@

Allergies:
@ALLERGY@

Medications:
@CMED@

Physical Exam:

Vital signs: @V(3)@

@LASTWT(3)@
Constitutional: well-developed, appearing stated age; cooperative.
Eyes: EOMI, PERRLA. Conjunctiva is not injected, sclera is anicteric. Visual
fields intact by confrontation.
ENT: Auricle, nares, lips, teeth, gums, throat are unremarkable. No mucous
membrane lesions, normal saliva pool. Rinne AC>BC bilat; Weber midline.
Neck: no mass or thyroid enlargement.
Pulmonary: No SCM retraction. Thoracic cage expansion is symmetric and
unrestricted. No tactile fremitus or dullness on percussion noted. CTAB.
Cardio: RRR, no murmurs, rubs or gallops; no LE edema.
Vascular: Carotid, radial and DP pulses are 2+ and regular, bilaterally.
GI: Borborygmi x4Q. Abdomen is NT/ND and tympanic throughout. No HSM
noted; -ve Murphys sign. No guarding or rebound tenderness.
GU: no lesions noted.
Lymph: no cervical, supraclavicular, inguinal or epitrochlear nodes
MS: No active synovitis, Full ROM. Grip strength WNL.
Skin: No nail pitting, rash, nodules or lesions.
Neuro: nl cranial nerves, strength, sensation, DTRs.
Psych: nl judgement, orientation, memory, affect.

Data:

@THISVISIT@

Hennepin County Medical Center

Inpatient Medicine
Medical Student Note

@IPHEADER@
Admitted on: @Admitdttm@
Primary care provider: @PCP@
Attending physician: @ATTPHYS@

Summary:

@NAME@ is a @AGE@ @SEX@ with a PMHx of ***, admitted on @ADMITDT@ due to

***, now ***.

Active Problem List:

@PROBL@

Subjective:

@NAME@ is a @AGE@ @SEX@ who presents for ***. @FNAME@ has a PMHX of
@PMHXThe chief complaint of today's visit is ***. The history of present illness begins ***,
when @FNAME@ relates having ***. This was associated with *** and would be worst at
***. This complaint is alleviated by *** . It is aggravated by ***.

Review of Systems
Constitutional: No fevers, night sweats, chills, Cardiovascular: No precordial pain,
myalgias or drastic changes in weight. orthopnea or palpitations.

Skin: No new worrisome lesions, rashes or Gastrointestinal: No emesis, heartburn,

ulcerations. No unexplained bleeding or melena, No change in BM frequency or in
bruising, eruptions or pruritus. stool consistency.

Eyes: No acute changes to vision, pruritus, Genitourinary: No urgency, no changes in

scotomata or oculodynia. No diplopia or
ametropia. No xerophthalmia.
Ears: No changes in hearing or balance; no
pain, discharge, inflammation. No tinnitus. No
vertigo.
Nose/Throat/Mouth: No abnormal odors,
changes to appetite. No rhinorrhea, epistaxis,
odynophagia, dysphonia or ulcerations.
Respiratory: No SOB, DOE, tussis, wheezing,
frequency, color. No dysuria or hematuria.
Musculoskeletal: No arthralgias or
myalgias. No recent weakness or loss of
strength.
Neuro/Psych: No cephalgias, convulsions,
LOC, or tremors. No sudden changes in
mood or feelings of self harm.
Endocrine: No polydipsia, polyphagia, or
altered temperature sensitivity.
or hemoptysis. No sputum changes.

Objective:
@V@
@LASTWT(4)@

Constitutional: well-developed, appearing stated age; cooperative.

Eyes: EOM: ***
Pupils: ***. Conjunctiva is not injected, sclera is anicteric. Visual fields
intact by confrontation.
ENT: Auricle, nares, lips, teeth, gums, throat are unremarkable. No mucous
membrane lesions, normal saliva pool. Rinne AC>BC bilat; Weber midline.
Neck: no mass or thyroid enlargement.
Pulmonary: No SCM retraction. Thoracic cage expansion is symmetric and
unrestricted. No tactile fremitus or dullness on percussion noted. CTAB.
Cardio: RRR, no murmurs, rubs or gallops; no LE edema.
Vascular: Carotid, radial and DP pulses are 2+ and regular, bilaterally.
GI: Borborygmi x4Q. Abdomen is NT/ND and tympanic throughout. No HSM
noted; -ve Murphys sign. No guarding or rebound tenderness.
GU: no lesions noted.
Lymph: no cervical, supraclavicular, inguinal or epitrochlear nodes
MS: No active synovitis, Full ROM. Grip strength WNL.
Skin: No nail pitting, rash, nodules or lesions.
Neuro: nl cranial nerves, strength, sensation, DTRs.
Psych: nl judgement, orientation, memory, affect.

Laboratory Results:

@LABRCNTCHEM@
@LABRCNTHEME@
@LABRCNT(UAGLU:1,UABIL:1,UAKET:1,UASG:1,UARBC:1,UAPH:1,UAPRO:1,
UAURO:1,UANIT:1,UALEUK:1)@
@URCXRESULTS@
@MICROLABS@

Assessment and Plan by Problem:

1. ***
***
2. ***
***

Thank you for allowing my participation in the care of @NAME@.

COPD, T2DM, h/o DVT on anticoagulation, frequent falls and GERD
Sincerely,

@ME@
University of Minnesota Medical School

@NAME@ was seen with @ATTPHYS@, who agreed with the findings

described.