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Name: Hospital Universitan'o' Dr.

Ramón Ruiz Arnau EM l _


Bayamón, PuertoRico ‘1‘",
Department of Internal Medicine a.“ y “,v' 3.1;. r

MRN: Admission History & Physical Examination

NATURE AND DURATION OF CHIEF COMPLAINT:

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 '

———_
_—__r —
ihm"
_———
MEDICATlONS: -———_—]—————I’.
.
_—
“__r ——_-—--
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

ALLERGIES.‘ Ü No known drug allergies l] Latex Ü Food


Specify:
SOCIAL HISTORY-2 ccupation: ÜUnemployed Man'tal StatuszE] Married DSingle DDívorced El Widow/er
ravel history: ÜDenied
El Alcohol:
I:]Denied ousing: Ü Urban house El Apartments El Farm
. ÜQuit: Ü Homeless ÜOther.
ÜTobacco: Packs/yr [:lllliterate
DCounseled about cessation ÜNever
'ves with:

E] Illicit drugs:

FAMILY HISTORY:
El Living g“; o High Blood Pressure o Diabetes a High Cholesterol/Fats
5
71
N

El Deceased Agei_ I] Cancer: Type [I Other


D Living gAe'_—l El High Blood Pressure El Diabetes [J High Cholesterol/ Fals
E
5’-
o

El Deceased Age:__ El Cancer: Type l] Other


l] living ause Of Death D High Blood Pressure I] Diabetes El High Cholesterol/ Fats
Q
5
c-

D Deceased - El Cancer: Type El Other


D Living Ü High Blood Pressure I] Diabetes l] High Cholesterol] Fats
5
0
co

El Deceased Age: I] Cancer:T e El Other


SCREENING HISTORY Please state the date of the screening that applies if any
Screening Date

Breast Cancer Lipid disorders (man 35 y/o. woman 45 y/o)


Cervical cancer Chlam dial Gonorrhea
Colorectal cancer HBV/ HCV/ HIV I S hílis
Lun Cancer Alcohol misuse
_ DM2 + A-HTN
Osteoorosis
Other Other
TRAN SF USION HISTORY Please state the date and an oomlication of the transfusion

RESIDENT PHYSICIANS SIGNATURE DATE l TIME Page 2 of 6


Hospital Universitario Dr. Ramón Ruiz Arnau
Bayamo’n, PuertoRico
Department of internal Medicine
Admission History & Physical Examination

General - weight loss, weight gain, fever, chills, night sweats, fatigue,
malaise

Skin — rash, dryness, cyanosis, jaundice, pruritus, abscess, mass

Eyes - visual changes, eye pain, redness, secretions, lacn'mation,


photophobia, sootomas, floaters, icterus

Ears — Hean'ng deficit, earache, secretions, bleeding, tinnitus, vertigo

Head — Headache, trauma, masses, alopecia

Nose, Mouth and Throat — hoarseness, sore throat, sinus pain, coryza,
dysphagia, odynophagia, bleeding epistaxis, sinus symptoms, hearing
loss, tinnitus

Breast — Lumps, tenderness, secretions, skin retraction

Cardiovascular—faintness, syncope, chest pain, edema, paroxysmal


nocturnal dyspnea, orthopnea, palpitations, hypo/hypertension,
claudication, swelling ankles

ReSpiratory — dyspnea, cough, sputum, tachypnea, shortness of


breath, wheezing, hemoptysis

Gastrointestinal — abdominal pain, nausea, vomiting, diarrhea,


constipation, heartburn, blood in stool, dysphagia, bloating,
hematemesis, hematochezia, change in bowel habits, tenesmus

Genitoun'nary - dysuria, frequency, hematuria, incontinence, nocturia,


polyun‘a, difficulty starting stream, secretions, impotence, foul smell,
menstrual abnormalities, dripping, pregnant, P . G .A
'

LMP:
Endocrine — hot flashes. polyuria, polydipsia, polyphagía, heat/cold
intolerance, hair change, dry skin, mood swings, deep-voice,
masculinization, fem’inization, excessive sweating

Musculoskeletal — arthralgia, myalgia, weakness, joint swelling, back


pain, joint pain, stiffness, erythema, cramps, paralysis

Hematology/Lymphatic — bleeding, easy brusing, lymph node


swelling, night sweats, previous anemia, thrombocytopenia, leukopenia

Neurologic: numbness, tingling, weakness, headache, loss of


consciousness, seizures, paralysis, sensory deficit, gait disturbance,
speech abnormalities, memory deficit, tremors, imbalance, sphincter
dysfunction

Psychiatn’c - fatigue, insomnia, mood problems, crying, depression,


anxiety, hallucinations, Work problems, social problems

RESIDENT PHYSICIAN'S SIGNATURE DATE I TIME Page 3 of 6


Name: Hospital Universitario Dr. Ramón Ruiz Arnau pan-1%.;
'EI—
' --
1 -»
n; r .,- I n:

Bayamón, PuertoRico EV x 'p- ¡L u


Department of Internal Medicine "¿y '- '

i
MRN: Admission History & Physical Examination

Physical Examination: N: Normal A=Abnormal (if Abnormal please descn'be)


2
CU
"J.
> T: P: BP: I RR: Pain I10 SaOz.‘ % Height: Weight: BMI: IBW:

lil Abnormal Findings Descripn'ons


«3" ‘w"a'k‘e‘,'A“Ien',"0n'e'n‘ted"(tim‘e‘,'p‘|a"ce“"',p’e73o’n”), No"A'c‘u’te‘d"Is'tr’e"s"s,“ No‘Ac’u’te’ble‘W‘rng,
I—
d) ell appean'ng, Development, Noun'shment, Detormities, Attention to grooming,
C
G.) omprehension and language skills
(D

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

‘U dequate shape, no tenderness, no scars and adequate size


(U
O

onjunctivae, Pupillary light reflex (direct and consensual) accommodation, Corneal


In
G) oudiness or cataracts, Extraocular movements (EOM), exophthalmos, ptosis,
> isual acuity, and convergence, Visual fields by confrontation, Ophthalmoscopy
exudate, hemorrhages, papilledema)
External canals, Timpanic membranes, gross hean'ng, Weber test, Rinne test,
o osoopy
Nasal mucosa, septum, sinuses

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

Male: penis, scrotum, hair distn'bution, Female: External genitalia, Cervix,


masses, swollen gland, tenderness Uterus/adnexa, hair distn‘bution, masses,
swollen gland, tenderness,

RESIDENT PHYSICIAN’S SIGNATURE DATE / TIME Page 4 of 6


Hospital Universitan'o Dr. Ramón Ruiz Arnau , x
Bayamón, Puerto Rico E 1: ¡"L-I,
Department of lntemai Medicine .. r.

.
Admission History & Physical Examination

ASSESSMT I 7 i

DIFFERENTIAL DIAGNOSIS

IMPRESSION & PLAN

RESIDENT PHYSICIAN’S SIGNATURE DATE / TIME


E] [was present with the resident during the entire interview & examination of the patient. I repeated the key portions of the exam in the presence of the
resident. I confinned/revised the resident‘s history, exam, assessment & plan as noted in the margin. See resident’s notes for details.
1:] Iwas NOTpresent with the resident during the entire interview & examination of the patient. I personally interviewed the patient & repeated the exam.
I confinned/rew'sed the history, exam, assessment & plan as noted in the margin. See resident’s notes for details.

Teaching /A ttending Physician Signature Date / Time

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