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lofRi
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orinst
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e ad
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116
2974
1
PastMedi
calHi
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y(PMHx)–I
ncl
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us(
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ds ur
ger
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ngo
ntheCC,
morei
nfomaybenee
ded.
Pa
tie
ntre
por
tsimmun i
zat
ion
sa r
eu pt
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,as
thmadi
agnosi
sata
ge2 .
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soldtr
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ge2
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ncon
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alHi
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clu
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tli
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ndma j
orho
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es,
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s,t
oba
ccoa
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hol
use
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dan
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omoti
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tbelt
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imeorwo
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ngsmokedet
ect
orsi
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ouse.
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tie
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r.Doe
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nksal
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tharepor
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Pa
tie
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Pa t
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endschu
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egu
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ans
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amil
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i
pidemi
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Fa
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abe
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eas
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OMo
ARc
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1
629
741
SoapNot
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empl
atewi
thanswer
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l
OMo
ARc
PSD|
1
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629
741
, SOAPNot
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mpl
ate
Sub
ject
iv
e
I
nfor
mati
ont
hep
ati
ento
rpa
ti
entr
epr
ese
nta
ti
vet
ol
dyo
u
I
ni
ti
al
s:T.
J. Ag
e:2
8
Ge
nder:Fe
ma l
e
He
igh
t We
igh
t BP HR RR Te
mp SPO2 Pai
n Al
ler
gie
s(andr
eac
ti
on)
Ra
tin
g
1
70c
m 9
0kg 1
42/ 8
6 1
9 1
01.
1 9
9 Medi
cat
ion
:Peni
ci
ll
i
n-ras
h
8
2 Fo
od:none
En
vir
onment:
cat
s,d
ust–ast
hmat
ri
gge
rin
g
Hist
oryofPr
esentI
ll
nes
s(HPI
)
Chi
efCompla
int(
CC) “f
ootwound” CCisaBRI EFsta
teme nti
denti
fyi
ng
Onset 1we e
kago whythepa t
ien
tishere- i
nthe
Loc
ati
on Bal
lofRi
ghtfoot pati
ent
’sownwo rds- f
orinst
ance
Dur
ati
on Ongoi
ngandincr
eas
ingp
ain "h
e ad
ache",NOT"ba dheadachefor3
days”
.Some ti
mesap a
tie
nthasmo re
Ch
aract
eri
sti
cs Pu
rul
entdr
ain
age
,warmt
h,e
ryt
hema,
ede
mat
ous th
a nonecomp l
ain
t.F o
rexamp l
e:I
f
Aggr
ava
tin
gF ac
tor
s Wei
ghtbe
ari
ngcaus
es“s
har
p”pai
ns th
ep at
ientpre
sentswithcoughand
soret
hroat,i
dent
if
ywh ichistheCC
Re
li
evi
ngF
act
ors Pa
inme
dic
ati
on andwh i
chma ybea nassocia
ted
Tr
eat
men
t Da
il
yath
omed
res
sin
gch
ang
eswi
thNe
osp
ori
n symptom
Curr
entMe d
icati
ons:In
c l
uded o
sage
,fr
equenc
y,l
e ngt
hoft
imeu
sedandrea
sonforuse;
als
oincl
udeOTCorho meopat
hicp
roduct
s.
Me dicat
ion Do s
age Fr
equency Lengt
h ofTi
m e Rea sonforUse
(Rx
,OTC,orHomeopath
ic) Used
Provent
ili
nhal
e r 2-
3 puf
fs 2-
3 t
imesperweek Sin
cec hil
dhood As
thmaresc
uei n
h al
er
Tra
ma dol 50mg 2tabs3ti
me sperday 2days Ac
utepai
n(rfoot)
Cl
ickortapheret
o Cli
ckorta
ph er
etoenter Cli
ckort a
ph er
e Cl
i
ckorta
ph er
et oentert
ext
.
Cli
ckortaph er
etoe nte
rtex. e
t nt
ertext
. te
xt. toent
e rtex
t.
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ckortaph er
etoe nte
rtex. Cl
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ckorta
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ent
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xt. toent
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ckorta
ph er
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ext
.
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ckortapheretoentertext
. ent
ertext
. te
xt. toent
e rtex
t.
, l
OMoARc
PSD|
116
2974
1
PastMedi
calHi
stor
y(PMHx)–I
ncl
ude
sbutnotl
i
mite
dtoimmun
iza
ti
ons
tat
us(
not
eda
teo
fla
stt
eta
nusf
ora
lla
dul
ts
),p
astma
jori
l
lne
sse
s,h
osp
it
al
iz
ati
ons
,
an
ds ur
ger
ie
s.Dependi
ngo
ntheCC,
morei
nfomaybenee
ded.
Pa
tie
ntre
por
tsimmun i
zat
ion
sa r
eu pt
odate
,as
thmadi
agnosi
sata
ge2 .
5year
soldtr
eat
edwithres
cuei
nha
ler
,DM2di
agn
osi
sata
ge2
4–u
ncon
trol
l
ed.
Pr
evi
oushos
pit
ali
zat
ionsi
nclud
ea sachi
l
dforast
hmaat
tack
.Noprev
iouss
urger
iesr
epor
ted
.L a
steyee
xamasachi
l
d.
Soci
alHi
stor
y(SocHx)-In
clu
desbutno
tli
mit
edtooc
cupa
ti
o na
ndma j
orho
bbi
es,
famil
yst
atu
s,t
oba
ccoa
nda
lco
hol
use
,an
dan
yot
herp
ert
in
entd
ata
.In
clu
deh
eal
th
pr
omoti
onsuchasusesea
tbelt
sal
lt
h et
imeorwo
rki
ngsmokedet
ect
orsi
ntheh
ouse.
Pa
tie
nti
sanon-s
mok e
r.Doe
sn o
tu ser
ecre
a t
ion
ald
rug
s.Dri
nksal
coholsoc
ial
lywi
tharepor
ted2-
3dri
nksperev
entseve
ralt
imesamont
h.
Pa
tie
nti
semploy
edandas t
udentwork
ingtowar
dsaBach
e l
or’
sdegr
ee.
Pa t
ien
trepor
tss
heliv
eswit
hmot h
erandsi
ster
.Att
endschu
rchr
egu
lar
ly
.
Pa
tie
ntr
epor
tsacce
sstoheal
thinsu
ranceandtr
ans
por
tat
ion.Hob
biesi
ncl
udewa t
chi
ngDVDsa n
ds t
rea
mingte
levi
si
on.
F
amil
yHis
tory(
FamHx)-I
nclu
desbutno
tli
mit
edt
oil
l
ness
eswit
hposs
ibl
egene
ti
cpred
ispos
it
ion,
conta
giouso
rchr
oni
cil
ln
es s
es.Rea
sonf
ord
eat
hofa
ny
d
ece
asedf
irs
tdegr
eer
el
ati
vessho
uldbei
ncl
ude
d.I
ncl
udep
are
nts
,gr
andpa
ren
ts,s
ibl
i
ngs,a
ndc h
il
dren
.Incl
udegr
and
chi
ld
renifper
ti
nent
.
Mother–hypert
ensi
on ,
hyperl
i
pidemi
a
Fa
ther–h yper
ten
sion,hyp
erl
ipi
demia,di
abet
estype2
Si
ste
r–As thma
Br
other–n oheal
thprobl
ems
Mater
n a
lgrandmoth
er–h yper
tensi
on,hy
perl
ipi
demia,MI(de
cease
d)
Mater
n a
lgrandf
athe
r–h ypert
ensi
on,hype
rli
pi
demia,CVA(dece
ased)
Pat
ernalgr
a n
dmother–h ype
rten
sion,
hyperl
i
pidemia
Pat
ernalgr
a n
dfat
her–h yper
tens
ion,
hyperl
ipi
demia,
d i
abe
testy
pe2,col
onc
anc
er(
dec
eas
ed)
NoChildr
en
