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--- ummc:va:cprs_templates [2023/11/01 19:10] – admin
+++ ummc:va:cprs_templates [2023/12/18 14:51] (current) – [Clinic Note] admin
@@ Line 24: / Line 24: @@
 Assessment / Plan
-M with history of x, initially admitted for X, now with x.
+@@-year-old with history of x, initially admitted for X, now with x.
-Acute hypoxemic respiratory failure
+@@
-Septic shock from GNR bacteremia
-Acute kidney injury, grade 2
 Recommendations
-- XX
+- xxx
 - xxx
 Subjective
-- overnight, no acute events - reports no specific concerns
+-
-Full ROS performed. Negative except as mentioned above.
+Environmental exposures:
+[ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers
+[ ] hot tub use
+[ ] pets/ birds at home
+[ ] playing any wind instruments
+[ ] hobbies such as wood working
+[ ] mold/water damage in the house
+Military-specific exposures:
+[ ] Agent orange - Vietnam War
+[ ] Depleted Uranium - Gulf War
+[ ] Asbestos - Navy due to shipyards
+[ ] Mustard gas – WWI
+[ ] Particulate matter
+[ ] Burn pit
+[ ] Chromium
+Occupational exposures outside the military :
+[ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters
+[ ] Ionizing radiation - uranium mining
+[ ] Vinyl chloride - pulp & paper workers
+[ ] Arsenic - smelting of ores, pesticide application, wood preservation
+[ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers
+[ ] chromium - stainless steel production, welding, tanning industries
+[ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters
+PMH:
+|ACTIVE PROBLEMS|
+Medications:
+|ACTIVE MEDICATIONS|
+Allergies:
+|ALLERGIES/ADR|
+|999Y1 PNEUMO|
+|999Y1 FLU,WHOLE|
+SH:
+Functional status: @@
+[ ] fully independent in ADLs and IADLs
+[ ] uses cane at baseline
+[ ] uses walker at baseline
+[ ] uses wheelchair at baseline
+[ ] uses oxygen at baseline
+[ ] Tobacco Smoking –
+Age of onset of smoking: years
+Duration of smoking: years
+Maximum packs/day:
+Current cigarettes /day:
+Any alternate tobacco product
+[ ] cigar,
+[ ] pipe,
+[ ] waterpipe
+[ ] Vape/e cigarettes
+[ ] Second hand smoking
+[ ] Indoor emission from household combustion
+[ ] Outdoor air pollution
+ROS:
+Constitutional: No fevers, chills, sweats, weight change, or fatigue
+Eyes: No itchy, watery eyes, no blurry vision
+ENMT: No sinus/nasal congestion, rhinorrhea, post-nasal drip
+Skin: No Rash
+CV: No chest pain, palpitations, PND, orthopnea
+Respiratory: As above.
+GI: No heartburn
+MSK: No joint pains/myalgias
+Neuro: No numbness/tingling
 Objective
-Vitals: Tmax x
+Vitals:
+|VITALS|
-Exam: RRR.CTAB
+Exam:
+General: NAD, alert, WD, WN
+Eyes: PERRL, no scleral icterus
+ENMT: oropharynx clear, good dentition, no oral lesions, mallampati score @@
+Skin: warm, intact, no rashes
+Neck: ROM and lymph node assessment
+LN: axillary, supra-clavicular, and inguinal lymph node assessment
+CV: RRR, no MRG, nl S1 and S2, no peripheral edema
+Resp: clear to auscultation bilaterally, no wheezes, rales, or rhonchi, normal effort, no clubbing/cyanosis
+Abdom: Normoactive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly
+Neuro: Awake alert oriented to person place time and situation
 Labs & Imaging: All labs and imaging within past 24 hr personally reviewed by me.
+|PFT |
+|CHEST 2 VIEWS PA&LAT|
+|CHEST CT|
+</code>
+=====Clinic, Lung Mass=====
+<code>
+Lung Mass Consult:
+Reason for Referral: Nodule / Mass in
+HPI:
+Environmental exposures:
+[ ] oil diffusers/scented candles/glade/Airwick plugins/incense sticks/ oil in humidifiers
+[ ] hot tub use
+[ ] pets/ birds at home
+[ ] playing any wind instruments
+[ ] hobbies such as wood working
+[ ] mold/water damage in the house
+PMH:
+|ACTIVE PROBLEMS|
+Medications:
+|ACTIVE MEDICATIONS|
+Allergies:
+|ALLERGIES/ADR|
+|999Y1 PNEUMO|
+|999Y1 FLU,WHOLE|
+SH:
+[ ] Tobacco Smoking –
+Age of onset of smoking: years
+Duration of smoking: years
+Maximum packs/day:
+Current cigarettes /day:
+Any alternate tobacco product
+[ ] cigar,
+[ ] pipe,
+[ ] waterpipe
+[ ] Vape/e cigarettes
+[ ] Second hand smoking
+[ ] Indoor emission from household combustion
+[ ] Outdoor air pollution
+Military-specific exposures:
+[ ] Agent orange - Vietnam War
+[ ] Depleted Uranium - Gulf War
+[ ] Asbestos - Navy due to shipyards
+[ ] Mustard gas – WWI
+[ ] Particulate matter
+[ ] Burn pit
+[ ] Chromium
+Occupational exposures outside the military :
+[ ] Asbestos - construction workers, elictricians, mining, railroad, fire fighters
+[ ] Ionizing radiation - uranium mining
+[ ] Vinyl chloride - pulp & paper workers
+[ ] Arsenic - smelting of ores, pesticide application, wood preservation
+[ ] Beryllium - ceramic workers, missile technicians, nuclear reactor workers, jewelers
+[ ] chromium - stainless steel production, welding, tanning industries
+[ ] Nickel - battery makers, ceramic makers, electroplaters, glass workers, jewelers, metal workers & welders, painters
+FH:
+[ ] Relatives with hx of lung cancer
+[ ] Relatives with other types of cancer
+[ ] Family history of lung disease:
+STOP-BANG Score:
+[ ] Snoring - do you snore loudly?
+[ ] Tired - do you feel tired, fatigued, or sleepy during daytime?
+[ ] Observed apneas?
+[ ] Pressure - hx of high blood pressure?
+[ ] BMI?
+[ ] Age > 50?
+[ ] Neck circumference: > 16 inch or 40 cm collar?
+[ ] Male Gender
+Hx of Anesthesia reactions:
+[ ] Prior surgeries and anesthesia reactions
+[ ] Hx of difficult intubation
+[ ] Family Hx of malignant hyperthermia
+ROS:
+Constitutional: No fevers, chills, sweats, weight change, or fatigue
+Eyes: No itchy, watery eyes, no blurry vision
+ENMT: No sinus/nasal congestion, rhinorrhea, post-nasal drip
+Skin: No Rash
+CV: No chest pain, palpitations, PND, orthopnea
+Respiratory: As above.
+GI: No heartburn
+MSK: No joint pains/myalgias
+Neuro: No numbness/tingling
+Exam:
+VS:
+|VITALS|
+General: NAD, alert, WD, WN
+Eyes: PERRL, no scleral icterus
+ENMT: oropharynx clear, good dentition, no oral lesions, mallampati score @@
+Skin: warm, intact, no rashes
+Neck: ROM and lymph node assessment
+LN: axillary, supra-clavicular, and inguinal lymph node assessment
+CV: RRR, no MRG, nl S1 and S2, no peripheral edema
+Resp: clear to auscultation bilaterally, no wheezes, rales, or rhonchi, normal effort, no clubbing/cyanosis
+Abdom: Normoactive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly
+Neuro: Awake alert oriented to person place time and situation
+Data:
+|PFT |
+|CHEST 2 VIEWS PA&LAT|
+|CHEST CT|
+https://www.mdcalc.com/calc/3910/duke-activity-status-index-dasi
+ASA grade:
+[ ] ASA I - normal healthy patient
+[ ] ASA II - a patient with mild systemic disease
+[ ] ASA III - a patient with severe systemic disease
+[ ] ASA IV - a patient with severe systemic disease that is a constant threat to life
+Karnofsky Performance Status Scale (mdcalc.com)
+Assessment: Solitary Pulmonary Nodule Malignancy Risk (medscape.com)
+Plan:
+I discussed the above plan with the attending, Dr. Janaki Deepak.
+IP attending Dr. was also present to staff this patient
 </code>

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