Inpatient Sample Chart 2 ED

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EMERGENCY DEPARTMENT

History of Present Illness

The patient presents with difficulty breathing.  The onset was 2 days ago.  The course/duration of symptoms is worsening.  Degree at onset mild.  Degree at present moderate.  The Exacerbating factors is exertion.  The Relieving factors is rest.  Risk factors consist of asthma.  Prior episodes: rare.  Therapy today: beta-agonist albuterol and doctor's office visit.  Associated symptoms: chest pain and cough.  Additional history: Pt was seen at her physician's office, found to have an O2 saturation of 85% on room air, and was sent to the ED..  

 

Review of Systems

Constitutional symptoms:  Negative except as documented in HPI.

Skin symptoms:  Negative except as documented in HPI.

Eye symptoms:  Negative except as documented in HPI.

ENMT symptoms:  Negative except as documented in HPI.

Respiratory symptoms:  Negative except as documented in HPI.

Cardiovascular symptoms:  Negative except as documented in HPI.

Gastrointestinal symptoms:  Negative except as documented in HPI.

Genitourinary symptoms:  Negative except as documented in HPI.

Musculoskeletal symptoms:  Negative except as documented in HPI.

Neurologic symptoms:  Negative except as documented in HPI.

Psychiatric symptoms:  Negative except as documented in HPI.

Endocrine symptoms:  Negative except as documented in HPI.

Hematologic/Lymphatic symptoms:  Negative except as documented in HPI.

Allergy/immunologic symptoms:  Negative except as documented in HPI.

          Additional review of systems information: All other systems reviewed and otherwise negative.

 

Health Status

Allergies: 

Allergic Reactions (Selected)

Moderate

Azithromycin- Hives.

Keflex- Hives.

Penicillins- Hives..

Medications:  (Selected)

Documented Medications

Documented

Fetzima 120 mg oral capsule, extended release: 120 mg = 1 cap(s), Oral, Daily

ProAir HFA 90 mcg/inh inhalation aerosol: 2 puff(s), INH, q4hr, PRN: for wheezing

Singulair 10 mg oral tablet: 10 mg = 1 tab(s), Oral, qPM

amitriptyline 100 mg oral tablet: 200 mg = 2 tab(s), Oral, Once a day (at bedtime)

baclofen 20 mg oral tablet: 20 mg = 1 tab(s), Oral, TID

benzonatate 100 mg oral capsule: 100 mg = 1 cap(s), Oral, BID

busPIRone 15 mg oral tablet: 15 mg = 1 tab(s), Oral, TID

divalproex sodium 250 mg oral tablet, extended release: 750 mg = 3 tab(s), Oral, Once a day (at bedtime)

gabapentin 600 mg oral tablet: 600 mg = 1 tab(s), Oral, QID

hydrOXYzine hydrochloride 50 mg oral tablet: 50 mg = 1 tab(s), Oral, TID, PRN: for anxiety

hydroCHLOROthiazide 25 mg oral tablet: 25 mg = 1 tab(s), Oral, Daily

levothyroxine 150 mcg (0.15 mg) oral capsule: 150 mcg = 1 cap(s), Oral, Daily

meloxicam 15 mg oral tablet: 15 mg = 1 tab(s), Oral, Daily

pravastatin 20 mg oral tablet: 20 mg = 1 tab(s), Oral, Daily

ramelteon 8 mg oral tablet: 8 mg = 1 tab(s), Oral, Once a day (at bedtime)

tiZANidine 4 mg oral capsule: 4 mg = 1 cap(s), Oral, TID.

 

Past Medical/ Family/ Social History

Medical history: 

No active or resolved past medical history items have been selected or recorded..

Surgical history: 

Cesarean section

Arthroscopy of knee

FESS - Functional endoscopic sinus surgery

Hysterectomy  

Family history: 

No family history items have been selected or recorded..

Social history: 

Social & Psychosocial History

Social History

                Alcohol

                Denies Alcohol Use

 

                Substance Abuse

                Denies Substance Abuse

                Never

 

                Tobacco

                High Risk

                10 or more cigarettes (1/2 pack or more)/day in last 30 days Tobacco Use:.  3/4 pack per day.  15 year(s).

                10 or more cigarettes (1/2 pack or more)/day in last 30 days Tobacco Use:.

 

                Electronic Cigarette/Vaping

                Denies Electronic Cigarette Use

                Electronic Cigarette Use: Never.

 

Psychosocial History

                No active psychosocial history has been recorded.

Problem list: 

Active Problems (8)

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

General:  Alert, moderate distress. 

Skin:  Warm, dry, intact. 

Head:  Normocephalic, atraumatic. 

Neck:  Supple.

Eye:  Extraocular movements are intact.

Ears, nose, mouth and throat:  Oral mucosa moist.

Cardiovascular:  Regular rate and rhythm.

Respiratory:  Respirations: Tachypneic, Breath sounds: Rhonchi present. 

Gastrointestinal:  Nontender.

Back:  Normal range of motion.

Musculoskeletal:  Normal ROM.

Neurological:  Alert and oriented to person, place, time, and situation.

Psychiatric:  Cooperative.

 

Medical Decision Making

Differential Diagnosis:  Pneumonia, congestive heart failure, pulmonary embolism, chronic obstructive pulmonary disease, asthma, pleural effusion. 

Electrocardiogram:  rate 97, normal sinus rhythm, No ST-T changes, The Axis is normal.  , P wave and PR interval Left atrial enlargement. 

 

Impression and Plan

Diagnosis

Community acquired pneumonia

Hypoxia