CC: SOB x ... hours/days
HPI:
Onset
Setting in which occurred - what Pt was doing at that time
Manifestations: ChLoRIDE PP (not necessarily in this order)
Character
Location
Radiation
Intensity or severity
Duration and time course
Events preceding onset of the complaints
Provoking/Exacerbating factors/Aggravating factors
Palliating/Alleviating factors
Similar problem before
Pertinent +ve and -ves: (may record some in ROS)
N/V/D.
Dypnea, othopnea, PND, swelling (peripheral, periorbital, anasarca), ascites.
CP, palpitations, diaphoresis, syncope
HA, dizziness, light-headed, blurred vision, sz, weakness, numbness, paresthesiae.
Fever, chills, rashes, cough, +/- sputum, wheezing, sorethroat, rhinorrhea, arthralgia.
Claudication, calf pain
Exposure to sick contacts, recent travel
GIB
Does Pt make urine?
dysuria, hematuria, flank pain, etc.
HD days, last HD, access site, problems with graft, shunt, fistula, permacath.
Previous ABx therapy.
Compliance with meds, diet, and fluids.
PPD, Flu shot this year, pneumonia vaccination.
ER w/up, Tx given
ALLERGIES:
MEDS:
PMH:
ESRD on HD, since when?
Dialysis center - where?
Nephrologist
Access - AVF, AV graft, HD catheter
MI, CAD, HTN, CHF, PCI, 2D-echo (LVEF), DCM, PPM, AICD, arrhythmia
DM
COPD, Asthma, Pneumonia, Prior intubations
Stroke
CA
PUD
PVD
DVT
EGD, Colonoscopy
Hepatitis-B, C
PSH:
OB&GYN (if pertinent)
FMH:
SH:
Tobacco use pk/yrs; rec. drugs type/amt/freq/last use; ETOH type/amt/freq/last use; env. hazards, use of safety devices, home situation and significant others; social support systems); ADLs and IADLs, diet, caffeine, sleep pattern, level of education, emp. hx, sexual activity, risk behavior profile, exercise and leisure activities, travel, impact of illness on the patient's life-as a person, worker, spouse, and parent.
ADL/IADL
ROS: unremarkable apart from the above symptoms