137 - Psych / OD

Addressograph

Date: _____________________ BP: ___ / __ T: ____________

Time Seen: _________________ P: __________ R: ___________
PMD: ______________________ Pulse Oxi: ______ % on_______ Allergies: NKA Current Medications: None
Chief Complaint:

Check box [ ] for normals, circle positives, slash negatives, note findings [ ] Nurse Assessment Reviewed WT: __________

History of Present Illness: Review of Systems:

Brief = 1-3; Extended = 4+

Problem Pertinent = 1; Extended = 2-9; Complete = 10+

Onset / Timing: [ ] Constitutional: (F / C)

[ ] Eyes: (visual disturbance)

[ ] Neck: (stiff)
Location:
[ ] Cardiovascular: (shortness of breath, CP, syncope, dizzy, palpitations)

[ ] Respiratory: (cough, sputum, hemoptysis, pleuritic)

Quality: (suicide attempt / ideation) [ ] Gastrointestinal: (abd pain, GI bleeding, N / V / D)

[ ] Genitourinary: (dys / freq, hematuria, pregnant, LMP _________)

[ ] Musculoskeletal: (weak, numb, coordination, ambulation)

Severity:
[ ] Integumentary: (diaphoresis, pallor, rash)

[ ] Neurological: (headache, h/o stroke / TIA)

[ ] Psychiatric: (depression, anxiety, psych dx)

Duration:

[ ] Endocrine: (diabetes, thyroid dz, Addison dz)

[ ] Hematologic/Lymphatic: (bruising, bleeding, anticoagulation)

Context: (situational problems) [ ] Allergic/Immunologic: (splenectomy)

[ ] All others negative:

Modifying Factors
alleviated by: Past, Family, and Social History:
Pertinent = 1 of 3; Complete = 2 of 3

Childhood Immunizations: [ ]Y [ ]N
exacerbated by:
Tetanus current: [ ]Y [ ]N

[ ] Previous Trauma:
Associated Signs / Symptoms: (HA, F / C, stiff neck, weak, depression, seizure,
agitation, hallucination, confusion, coma)
[ ] Surgeries / Procedures:

[ ] Previous Illness / Hospitalizations: (HTN, DM, chol, prior MI, DVA, TIA,
SBE, arrhythmia)
Prior similar episodes
workup:

[ ] Family Hx: (CA, HTN, CVA, DM, CV, SZ, sudden death)
diagnosis:
master1r998o0vow-137-05022007-1017

[ ] Social Hx: Tobacco___________ EtOH _____________ Drugs __________

treatment:

Hx obtained from: [ ] Hx Unavailable

Copyright © 1999-2007, EvolveMed Photocopying without permission is prohibited Licensed to: Page 1 of 2
 137 - Psych / OD
Check box [ ] for normals, circle positives, slash negatives, note findings

Physical Exam: Medical Decision Making:

Comprehensive = 8+ Organ/Areas

General Appearance: Differential Diagnosis: circle possible dx’s

[ ] well developed, well nourished *Meningitis Psychosis Encephalopathy
*CVA Dementia Intoxication
OD, intentional Bipolar Drug toxicity
Eyes: Suicide attempt Borderline personality Hypoxemia
[ ] PERRL [ ] fundi OD, accidental Poisoning Infection
Decompensated psych dz Seizure Medical clearance
Depression Hypoglycemia Other:
Problem Focused = 1+ Organ/Areas; Detailed = 5-7 Organ/Areas; Expanded Problem = 2-4 Organ/Areas

Diagnostic Tests:
Neck:
Lab: X-ray: LP / CSF: Cardiac monitor:
[ ] trachea [ ] no JVD
CBC CXR
[ ] thyroid [ ] no meningeal signs
CMP CT
ABG
U/A
tox
Respiratory:
ASA
[ ] auscultation [ ] effort
acetaminophen
BAL

Other Data Reviewed:

Cardiovascular: EKG:
[ ] PMI [ ] carotid pulses
[ ] RRR w/o murmur [ ] pedal pulses
[ ] abd aorta [ ] no edema / varicosities Pulse Oxi: ___% [ ] RA [ ] nl [ ] abnl
[ ] no bruits [ ] NC _________ L/min
[ ] mask ________ L/min

GI / Abdomen: Respiratory Therapy:

[ ] soft, NT w/o mass [ ] BS normal
[ ] no HSM [ ] CVAs NT old records: [ ] requested [ ] obtained [ ] unavailable
[ ] stool guaiac [ ] no hemorrhoids old records: [ ] reviewed [ ] summarized
additional Hx from family, caretaker, other _______________________________
crisis eval.:

Musculoskeletal:
Head: Neck: Treatments / Management Options / Course:
[ ] NC / AT [ ] strength / tone / ROM

Back / Spine: Chest:

[ ] strength / tone / ROM [ ] no tenderness / deformity

Extremities:
[ ] strength / tone / ROM [ ] digits / nails
[ ] no tenderness / swelling [ ] gait / station

Skin:
[ ] good color, warm / dry [ ] no rash / lesion / mass
Clinical Impression(s):

Neurologic:
[ ] CN II XII intact [ ] sensation nl throughout Disposition: [ ] Home [ ] Admitted [ ] Transferred
[ ] reflexes are all 2+ / equal bilat [ ] strength nl bilat in all extremities
Condition: [ ] Unchanged [ ] Improved [ ] Stable
master1r998o0vow-137-05022007-1017

Psychiatric: Follow up:

[ ] nl judgement / insight [ ] recent / remote memory intact
[ ] oriented x3 [ ] mood / affect appropriate to setting
Copies to:

Signatures: Date: Dict: Y N

[ ] Exam limited by urgency of condition. Dict: Y N

Copyright © 1999-2007, EvolveMed Photocopying without permission is prohibited Licensed to: Page 2 of 2