ScribeAmerica- HPI, ROS, PE, Hospital Course, & Discharge Summary

1. History of Present Illness2. Review of Systems3.

Past History4. Physical Exam5. Hospital Course6. Assessment and Plan

1. Subjective Summary2.

Physical Exam3. Hospital Course4. Assessment and Plan

1. Admitting Dx2. Discharge Dx3.

Hospital Course4. Discharge Plan5. Medication Reconcillation

1. Onset (when did it begin)2. Timing (constant, intermittent, or waxing and waning)3.

Location (where is it)4. Quality (sharp, dull, aching, cramping)5. Severity (how bad, 1-10)6. Modifying factors (what makes it better or worse)7. Associated symptoms (what else happens)8.

Context (is that anything else important related)

1. Look at patient2. Auscultating heart/lungs3. Palpating abdomen 4.Examining legs

Normal= alert, NADAbnormal= distress, malnourished, cachectic, somnolent

Normal= AT/NCAbnormal= sinus tenderness, angioedema

Normal= PERRL, EOMI, clear anterior chamber, sharp disc margins, normal corneaAbnormal= scleral icterus, pale conjuctiva, conjuctival injection, retinal detachment, papilledema, hyphema, corneal abrasion, fluorescein uptake

Normal= Normal auricle, pinna, normal external auditory canalAbnormal= pain with traction of the auricle/pinna or tragus, canal erythema, edema, debris

Normal= typanic membrane normalAbnormal= TM erythema, bulging, dullness, obscured by cerumen

Normal= normal naresAbnormal= epistaxis, rhinorrhea, septal hematoma, boggy turbinates, NG tube

Normal= OP normal, moistAbnormal= DMM, pharyngeal erythema, tonsillar exudate (strep throat), peritonsillar abscess (PTA), dental caries, edentulous

Normal= suppleAbnormal= JVD, Carotid bruit, cervical lymphadenopathy, vertebral point vs paraspinal tenderness

Normal= RRR (regular rate and rhythm)Abnormal= Tachycardia, bradycardia, IIR, murmur, extrasystoles, pleural rub, gallop

Normal= Pulses equal and symmetric, normal capillary refill (2+= easily palpable)Abnormal= delayed capillary refill (0,1+,3+,4+)

Normal= breath sounds clear and equalAbnormal= Respiratory distress, tachypnea, diminished breath sounds, wheezes, rales, chest tubes

Normal= soft and non-tender, normal bowel sounds, no organomegaly, no massAbnormal= tenderness, guarding, round tenderness, rigidity, abnormal bowel sounds, organomegaly, distended, murphy's sign, Mcburney's point tenderness

Normal= normal rectal exam, heme negativeAbnormal= Heme positive, abnormal stool color, hemorrhoids, decreased rectal tone, rectal prolapse

Normal= non-tender, full ROMAbnormal= bony tenderness, tendon laxity, decreased ROM, pitting pedal edema, calf tenderness

Normal= nontender thoracic and lumbar spineAbnormal= CVA tenderness, paraspinal tenderness, midline deformities

Normal= Warm, dry, normal color, no erythema/warmth/drainage, atraumaticAbnormal= Pallor, Cyanosis, Jaundice, Diaphoresis, Urticaria, Petechiae, erythema, increased warmth, induration (cellulitis), Fluctuance (Abscess), Lymphangitis, Ulcer, ecchymosis, contusion, abrasion, laceration, skin tear

Normal= alert and oriented x4, sensation intact, normal gait, motor strength (5/5) and equalAbnormal= somnolent, extremity weakness, hypoesthesia, numbness, aphasia, visual field loss, decreased DTRs, dysmetria, ataxia

High WBC (white blood cells)- infectionLow Hgb (hemoglobin)- anemiaLow Hct (hematocrit)- anemiaLow Plt (platelets)- prone to bleeding

High Bands- serious infectionHigh Segs- acute infectionHigh Lymphs- viral infectionLow Monos- bacterial infectionLow Eos- parasitic infection

High Na (Sodium)- DehydrationLow Na- DehydrationHigh BUN (blood urea nitrogen)- renal insufficiency/failureHigh Creat (creatinine)- renal insufficiency/failureLow GFR- renal insufficiency/failureHigh Gluc- high blood sugarLow Gluc- low blood sugar

Liver Function Tests (LFTs): Low T Prot/Alb- poor nutritionHigh T bili- jaundice, liver failureHigh AST (SGOT)- liver damageHigh ALT (SGPT)- Liver damageHigh Alk Phos- Liver damage

High Trop- specific to heart damageHigh CK- heart damage High CK-MB- heart damageHigh CK-RI- Heart damageHigh Myo- Heart damage

1. CBC2. BMP3.

CK, CK-MB4. Troponin5. EKG6. CXR

if negative, a PE or DVT can be excludedif positive, must receive a CTA Chest or VQ scan

Blood Culture Positive Growth- SepsisUrine Culture Positive Growth- UTI

High BNP (B-type Natriuretic Peptide)- CHFABG---> low pH= Acidosis, high/low HCO3= metabolic problem, high/low pCO2= respiratory problems, low pO2= hypoxia, VBG----> low pH (acidosis), high pH (alkalosis)Sputum Cx positive- Respiratory infection

Low CSF Gluc- possible bacterial meningitisHigh CSF Prot- possible meningitisCSF RBC- Subarachnoid hemorrhageCSF WBC- possible meningitisPositive CSF Gram Stain-bacterial meningitis

High PT (prothrombin time)- blood too thin>3.

0 INR- too much coumadin<2.0 INR- not enough coumadinHigh PTT (partial prothrombin time)- blood too thin

Positive Strep- Strep throatPositive Monospot- MononucleosisPositive Influenza A + B- "the flu"Positive RSV- Bronchiolitis

High Lip- PancreatitisHigh Amy- possible pancreatitis

High TSH- hypothyroidismLow TSH- HyperthyroidismLow T3- HypothyroidismLow T4- Hypothyroidism

High CRIP- Active inflammationHigh ESR or Sed Rate- Active inflammation

Positive HCG- PregnantPositive Serum HCG Qual- PregnantHigher Serum HCG Quant- Further along in pregnancy

Many clue cells- bacterial vaginosisMany trichomonas- Trichomonas (STD)Many yeast- Vaginal Yeast InfectionPositive GC- GonorrheaPositive CT- Chlamydia

Positive Leuks- likely UTIPositive Nit- UTIPositive Gluc- High blood sugarPositive Blo- Kidney stone vs. UTI

>6 WBC- UTI>6 RBC- UTI vs kidney stoneMany bacteria- UTI

High WBC, High Bands, High Lactate-sepsisBlood Cx- sepsis if positive

Large Ketones- DKAHigh Anion Gap- Metabolic acidosisHigh HgbA1c- poorly controlled diabetesHigh POC- hyperglycemia

CXR--> (PNA, PTX, Widened mediastinum, pleural effusion, CHF)AAS/KUB--> (free air (rupture), SBO, Constipation, large kidnney stones)All other X-rays---> (fractures, dislocation, foreign body)

CT head: hemorrhagic or ishemic CVACT C-spine: spine fractionCT Chest: PNA, PTX, rib fractureCT Abd/Pel: Kidney stones, pyelonephritis

CTA chest: PE, Aortic dissectionCTA Head: Hemorrhagic CVA, Ishemic CVACTA Neck: carotid dissection, carotid occlusion

Appendicitis, SBO, Diverticulitis, Ischemic gut

MRI: Hemorrhagic/ischemic CVA, brain tumors, herniated disc, spinal tumor, arthritis, bone tumors, torn cartilageMRA: Hemorrhagic/ischemic CVA, aneurysm, carotid artery disease, TIA

US Doppler LE: DVTUS Doppler Carotid: TIA, Carotid artery diseaseUS RUQ: Cholelithiasis, Cholecystitis, etcUS OB/Transvag: IUP, Ectopic pregnancy, Ovarian Torsion, cystUS Scrotum: Testicular torsion, mass

ultrasound of the heart; a-fib, valve dysfunctions, heart failure

1. BP 2. HR3.

RR4. Temp.5. O2 saturation

1. Constitutional 2. Eyes3.

Ears, nose, throat4. Cardiovascular5. Respiratory6. Gastrointestinal 7.

Genitourinary8. Musculoskeletal 9. Integumentary 10. Neurological 11.

Psychiatric 12. Endocrine13. Hematologic 14. Immunologic