Comprehensive Patient History

Dr. Nate

History of Present Illness ○ (-) anosmia, nasal congestion or

discharge,
○ (- dysphagia, hoarseness, neck
4 days PTA
pain/stiffness
○ Noted onset of loose bowel movement,
Heart and Lungs
watery, voluminous, non-bloody about ½ to
1 cup per bout noted 5X
○ (-) Orthopnea, PND, chest pain,
○ Accompanied by cramping abalminal pain
palpitations
4/10 on pain scale, no radiations, relieved
○ (-) dyspnea, SOB, hemoptysis
by defecation
○ Later in the day, noted moderate grade
GUT
fever, undocumented, intermittent,
(-) dysuria, gross hematuria, change in urine
temporarily relieved by Paracetamol 500
stream
mg tablet
(-) urgency
○ (+) anorexia
○ (-) vomiting, cough/colds, dysuria or
Musculoskeletal
myalgia
(-) arthralgia, joint stiffness
○ Patient tolerated condition
(-) limitations in ROM

Neurologic
1 day PTA
- No seizures, LOC, numbness nor paresthesia
○ Noted persistence of abovementioned
Hematologic
symptoms with no improvement
(-) bleeding, easy bruising
○ Diarrhea noted about 5x/day for the past
days
○ Noted vomiting of PIF, non-projectile,
non-bloody about ½ cup per bout, noted Ancilliary History
9X within a 24-hour period
○ No consult sought
Past Medical History
Few minutes PTA
○ No known comorbidities
○ Now wigeneralisedzed body ○ No allergies
weakness ○ No history of surgeries
○ Sought consult at ER and was diagnosed ○ No history of hospitalizations
as a case of AGE with Severe Dehydration ○ No previous blood transfusions
○ Primed transfer to higher facility but ○ (+) VA 1 month prior, sustained abrasions,
refused sought consult at BHU
○ No drug intake/maintenance medications
Review of Systems No herbal medications taken
○ Fully immunized under the EPI
General ○ With 2 doses of Astra Zeneca and 1Pfizer
○ (-) easy fatiguability booster dose for Covid-19
○ (+) light headedness ○ Hypertension on the maternal side of the
○ (-) night sweats family
○ (-) unintentional weight loss ○ No history of DM
○ (-) syncope ○ No history of MI, stroke or congenital heart
diseases
HEENT ○ No history of malignancies
○ (-) headache ○ No history of TB
○ (-) change in visual acuity, blurring of ○ No history of psychiatric disorders
vision ○ No history of blood dyscrasia
○ (-) hearing loss, ear pain, ear discharge,
ringing

Transcribed by: ACS

Comprehensive Patient History
Dr. Nate

Family History Chest:

- AP
- Tachycardic regular rhythm
- (-) murmur
- PMO non-displaced at 5th ICS MCL
Lungs
- SCE
- (-) retractions
- clear breath sounds

Abdomen:
- Flabby
- No scars/deformities
- No bruits
- Hyperactive bowel sounds
- Soft
Personal Social History
- Non-tender
- Non-smoker
- No masses palpated
- Occasional alcoholic beverage drinker,
- No organomegaly
about 1-2 bottles of beer on occasion
- No fluld wave
- Denies illicit/recreational drug use
- Denies history of recent travel, wading in
Extremities:
flood water etc,
- Cool clammy skin
- Weak peripheral pulses grade 1+
- CRT 2s
Physical Examination - No cyanosis
- No edema
- No varicosities
General: Conscious, coherent, weak-looking,
ambulatory with support, not in cardiorespiratory Neurologic:
distress, calm - GCS 15
- (-) sensorimotor deficits,
V/S: - gait changes
BP: 70/50 - CN I-XII intact
O HR: 122
RR: 20
T: 37 degrees Celsius
97% 02 sat at room air
Admission day (Initial)
Anthropometric measurements:
Ht: 168cm
Wt: 72kg
BMI 25.5 (overweight)

HEENT:
- Atraumatic head sunken eyeballs slightly
pale PC
- anicteric sclera, pupils 2-3 mm PERRLA,
- (-) nasal/ eye discharges
- (-) deformities and lesions dry lips and oral
mucosa
- neck supple, no CLADS
- trachea midline
- no jugular vein distension

Transcribed by: ACS

Comprehensive Patient History
Dr. Nate

Admission day (Reassessment after

first 500 cc of PLR)

Admission day (Reassessment after

1000 cc of PLR)

Admission day (Reassessment after

1500 cc of PLR)

Transcribed by: ACS