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A Source of infonnation: o Patient a Family in Old Chart c1 PCP u Sending Facility a Other:
HISTORY OF PRESENT ILLNESS:
'
PAST MEDICAL HISTORY: (include health maintenance & vaccines), also add onset date and severity ofthe disease.
Last influenza vaccine (month/year) l . DTP/Td l .
Pneumococcal vaccine month/ ear / . Heatitis B / . Y=
Y N omments _EIII
Con o estive Heart Failure
Arterial H ertension
Obstructive Slee o A nea
Corona Arte Disease
Stroke/TIA
Deressíon
_
Diabetes Mellitus T e
Asthma
C-OPD
CU
Cancer
r
Gastrointestinal disorders
PHYSICIANS SIGNATURE
RESID—__—‘—_—ENT DATE / TIME Page 1 of6
- Name: —_—__—___—___ HOSpital Universitario Dr. Ramón Ruiz Arnau “mug .‘-.'1«'In‘Llfl'-I.“|)-
i-l' VI",
Bayamo’n, PuertoRico ' É". :1 L' r" li 'l r. l’_ I r ¡_i
Department of Internal Medicine -' '
Admission History & Physical Examination '
———_
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_———
MEDICATlONS: -———_—]—————I’.
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D tem-me
—'—— I
.l Prescnbed
Date
Med_DorcatornNamese Route Frequency [I Lasatdose by
every _J- I
{Ta—mm.—
every _* l I
a... . .
l every
. ¡ every
every
every
E] Illicit drugs:
FAMILY HISTORY:
El Living g“; o High Blood Pressure o Diabetes a High Cholesterol/Fats
5
71
N
General - weight loss, weight gain, fever, chills, night sweats, fatigue,
malaise
Nose, Mouth and Throat — hoarseness, sore throat, sinus pain, coryza,
dysphagia, odynophagia, bleeding epistaxis, sinus symptoms, hearing
loss, tinnitus
LMP:
Endocrine — hot flashes. polyuria, polydipsia, polyphagía, heat/cold
intolerance, hair change, dry skin, mood swings, deep-voice,
masculinization, fem’inization, excessive sweating
i
MRN: Admission History & Physical Examination
onfiguration and pattern of any lesions. Hair (distn'bution and texture), loss of outer
1/3 of eyebmws, Nails color (pale, cyanotic), Nails shape, Palms color
ematous or anotic imented nodules s hills Soles lesions
dequate size, consistency, tenderness and matting (soft and tender, infection,
ea
IU)
ard cancer, lymphoma), Located at: Occipital, postaun’cular, preaun'cular,
:2
E
O ubmaxillary, submandibular, submental, anten'or and posten'or cervical, supra and
nfraclavicular, axillary, epitrochlear, inguinal
Ups, gums, teeth, Oropharynx, mucosa, salivary glands, Hard/soft palate, tongue,
nsils, posten'or pharynx, uvula, Gag reflex, Thyroid palpation, Neck (note brun‘,'
VD), supple
Throat]
oral/NECK
Inspect for scars, contour, symmetn'cal motion on breathing, shape and appearance
kyphosis, scoliosis, kyphoscoliosis) Pectus excavatum, pectus can'natum, point
endemess, Tactile fremitus, Percussion for resonance, dullness, flatness, tympani,
uscultation for breath sounds, crackles, wheezing, egophony, bronchophony,
hispered pecton'loquy, and rubs
I
Dimpling of skin, Tenderness, erythema, All quadrants and tail process of Spence,
illary nodes, nipple discharge (galactorrhea, blood and pus), Areolae
Breast
l- cars, pulsations, Point of maximal impulse (PMI), heaves, thn‘lls, lifts, Sitting and
L“
.2
'5 :3 ying down heart sounds (81,82), rubs, gallops (S3 and S4) and murmurs,
L. o
N m en'pheral edema, cyanosis or pallor, Pen'pheral pulses, Extremitles warm and well
U n:
> erfused. Capillary refill is less than 2 seconds. No carotid bruits.
Abdomen: Scars, Bruit, Mass, Tenderness, Hepatomegaly, Splenomegaly,
Bowel sounds positive, Stool Heme negative, anus, pen'neum, rectum, sphincter
tone, non tympanic
GASTRO
lNTESTlNAL
.
Admission History & Physical Examination
ASSESSMT I 7 i
DIFFERENTIAL DIAGNOSIS
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