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45 37 42

CHD A&W CHD

41 A&W

Figure 28-1 Family tree of patient John Doe. A&W, alive and well; Ca, cancer; CHD, coronary heart disease.

I I Male

Female Patient

15 A&W

Deceased male

Deceased female

Deceased male

Deceased female

Chlor-Trimeton, for colds Aspirin, for headaches Multivitamins with iron, daily

Family History (Fig. 28-1)

Father, 75, diabetes, broken hip Mother died, 64, stomach cancer Brother, 45, heart attack at age 40 Sister, 37, alive and well Son, 15, alive and well Wife, 41, alive and well

There is no family history of congenital disease. No other history of diabetes or cardiac disease. No history of renal, hepatic, or neurologic disease. No history of mental illness.

Psychosocial History

''Type A'' personality;born and raised in Middletown, New York;family moved to Rochester, New York, when Mr. Doe was 13 years of age;patient moved to New York City after high school; college and law school in New York City; he is now a senior partner of a law firm for which he has worked for the past 17 years;married to Emily for the past 13 years;was an active tennis player before second heart attack;before 6 months ago, enjoyed the theater and reading.

Sexual, Reproductive, and Gynecologic History

Patient is male, exclusively heterosexual, with one partner, his wife. He has one son, age 15 years. Recently, because of angina, the patient has stopped having sexual relations. He has noted that for the past 2 years his erections have been ''less hard.''

Review of Systems

General: Depressed for the past 6 months as a result of his ill health. Skin: No rashes or other changes. Head: No history of head injury.

Eyes: Wears glasses for reading;no changes in vision recently;saw ophthalmologist 1 year ago for routine examination;no history of eye pain, tearing, discharge, or seeing halos around lights.

Ears: Patient not aware of any problem hearing;no dizziness, discharge, or pain present.

Nose: Occasional upper respiratory infection, two or three times a year, lasting 3 to 5 days; no hay fever, sinus symptoms.

Mouth and throat: Occasional sore throats and canker sores associated with colds;no difficulty in chewing or eating; brushes and flosses twice a day; sees dentist twice a year; no gingival bleeding.

Neck: No masses or tenderness.

Chest: History of occasional blood-tinged sputum and cough in the morning when patient was smoking, but not recently;last chest x-ray film 1 year ago, was told it was normal;one-block dyspnea on exertion (as noted in History of Present Illness);no history of wheezing, asthma, bronchitis, or tuberculosis.

Breasts: No masses or nipple discharge noted.

Cardiac: As noted in History of Present Illness.

Vascular: No history of cerebrovascular accidents or claudication.

Gastrointestinal: Recent decrease in appetite with 10-pound weight loss in past few months; uses no laxatives; no history of diarrhea, constipation, nausea, or vomiting; no bleeding noted.

Genitourinary: Urinates four to five times a day;urine is light yellow in color, never red; nocturia X1;no change in stream;no history of urinary infections;no sexual intercourse in past 6 months, owing to angina during sex;no history of venereal disease.

Musculoskeletal: No joint or bone symptoms;no weakness;no history of back problems or gout.

Neurologic: No history of seizures or difficulties in walking or balance; no history of motor or sensory symptoms.

Endocrine: No known thyroid nodules; no history of temperature intolerance; no hair changes; no history of polydipsia or polyuria.

Psychiatric: Depressed and very anxious about his ill health;also anxious about the results of the upcoming cardiac catheterization;asked, ''What's going to happen to me?''

Physical Examination

General appearance: The patient is a 42-year-old, slightly obese white man who is lying in bed. He appears slightly older than his stated age. He is in no acute distress but is very nervous. He is well groomed, cooperative, and alert.

Vital signs: Blood pressure (BP), 175/95/80 right arm (supine), 175/90/85 left arm (supine), 170/90/80 left arm (sitting), 185/95/85 right leg (prone);heart rate, 100 and regular;respira-tions, 14.

Skin: Pink;no cyanosis present;five to seven nevi (each 0.5 to 1.5 cm in diameter) on back, most with hair; normal male escutcheon.

Head: Normocephalic, without signs of trauma.

Eyes: Visual acuity with reading glasses using near card: right eye (OD) 20/40, left eye (OS) 20/30;confrontation visual fields full bilaterally;extraocular movements (EOMs) intact;pupils are equal, round, and reactive to light (PERRL);eyebrows normal;conjunctivae pink; discs sharp; marked arteriovenous (AV) nicking present bilaterally; copper wiring present bilaterally; a cotton-wool spot is present at 1 o'clock position (superior nasal) in the right eye and at 5 o'clock position (inferior temporal) in the left eye; no hemorrhages are present.

Ears: Normal position; no tenderness present; external canals normal; Rinne test, air conduction > bone conduction (AC > BC) bilaterally;Weber test, no lateralization;both tympanic membranes appear normal, with normal landmarks clearly seen.

Nose: Straight, without masses; patent bilaterally; mucosa pink, without discharge; inferior turbinates appear normal.

Sinuses: No tenderness present over frontal or maxillary sinuses.

Mouth and throat: Lips pink; buccal mucosa pink; all teeth in good condition, without obvious caries; gingivae normal, without bleeding; tongue midline and without masses; uvula elevates in midline; gag reflex intact; posterior pharynx normal.

Neck: Supple, with full range of motion; trachea midline and freely mobile; no adenopathy present;thyroid not felt;prominent ''a'' wave seen in neck veins while lying at 45°; neck veins flat while sitting upright.

Figure 28-2 Diagram showing location of abnormal cardiac findings in patient John Doe.

Chest: Normal anteroposterior (AP) diameter;symmetric excursion bilaterally;normal tactile fremitus bilaterally;chest resonant bilaterally;clear on percussion and auscultation.

Breasts: Normal male, without masses, gynecomastia, or discharge.

Heart: Point of maximum impulse (PMI), fifth intercostal space, midclavicular line (5ICS-MCL);Si and S2 normal;normal physiologic splitting present;a loud S4 is present at the cardiac apex;no murmurs or rubs are heard (Fig. 28-2).

Vascular: Pulses are present and symmetric down to the dorsalis pedis bilaterally; no bruits are present over the carotid or femoral arteries; no abdominal bruits are present; no edema is present.

Abdomen: A well-healed appendectomy scar is present in the right lower quadrant (RLQ); the abdomen is slightly obese; no masses are present; no tenderness, guarding, rigidity, or rebound is present.

Rectal: Anal sphincter normal; no hemorrhoids present; prostate slightly enlarged and soft; no prostatic masses felt; no stool in ampulla.

Genitalia: Circumcised man with normal genitalia; penis normal without induration; testicles, 4 x 3 x 2 cm (right) and 3 x 6 x 4 cm (left) with normal consistency.

Lymphatic: No adenopathy noted.

Musculoskeletal: There are several stony-hard, slightly yellowish, nontender masses over the extensor tendons on the patient's hands;normal range of motion of neck, spine, and major joints of upper and lower extremities.

Neurologic: Oriented to person, place, and time;cranial nerves II to XII intact (cranial nerve I not tested); gross sensory and motor function normal; cerebellar function normal; plantar reflexes down;gait normal;deep tendon reflexes as in Table 28-1.

Summary

Mr. Doe is a ''type A'' 42-year-old man with a history of two myocardial infarctions, whose current admission is for elective cardiac catheterization. His risk factors for coronary artery disease are untreated hypertension and a long history of cigarette smoking. The patient has a brother who suffered a myocardial infarction at the age of 40 years.

Physical examination reveals a slightly obese man with hypertension and its associated early to intermediate funduscopic changes. Cardiac examination reveals a loud fourth heart sound, suggestive of a noncompliant (stiff) ventricle. This may be a manifestation of ischemic heart disease or ventricular hypertrophy secondary to the hypertension. Although the patient is not aware of any lipid abnormalities, numerous tendinous xanthomata on the hands are present, which are strongly suggestive of hypercholesterolemia, an additional risk factor for premature coronary artery disease.

Table 28-1

Deep Tendon Reflexes of Patient John Doe

Side

Biceps

Triceps

Knee

Achilles

Right

2+

2+

2+

1+

Left

2+

2+

1+

1+

Reflex scoring

: 2+, normal; 1+, diminished.

Table 28-2 Problem List for Patient John Doe

Problem

Date

Resolved

1. Chest pain

2004

2. Myocardial infarction

July 15, 2008

3 weeks later

3. Myocardial infarction

January 9, 2009

6 weeks later

4. Hypertension

Years

5. Smoking

1984

July 15, 2008

6. Tendinous xanthomata

?

7. S4 gallop

8. Dyspnea on exertion

6 months ago

9. Depression

3 months ago

10. Weight loss

3 months ago

11. Sleeping abnormality

3 months ago

12. Diet modification

3 months ago

13. Appendectomy

1982

The problem list containing all Mr. Doe's health problems, identified with their dates of recognition and resolution, might look like Table 28-2. This list is used each time the patient is seen and examined. For each problem, the clinician should develop a strategy for its ultimate resolution. Each problem should have the following four components:

Subjective data Objective data Assessment • Plan

This is the SOAP format (Weed, 1967), which contains an update of the subjective and objective data, as well as the assessment of the problem and the plan for its resolution. The heading of the progress note should include the date, the time, the name of the person who is writing the note, and the service the patient is using. It is very helpful to list the antibiotics and what day of the course of antibiotics at the top of the progress note, as well as other medications and doses. If the patient has undergone surgery, indicate postoperative time on the top as well (e.g., ''Postop Day #3'').

Subjective information is what patients tell you. How are they feeling? What are their symptoms? What are they eating? If their food status is NPO (nothing by mouth), note it here. How are they sleeping—well? How are they ambulating, urinating, defecating, and so forth?

If a patient tells you that he or she is ''not doing well,'' you should not write this in your note, because this may be misinterpreted as your assessment. Instead, obtain a description of the reason the patient feels he or she is not doing well.

Objective information is what you gather from your physical examination, laboratory tests, and radiographic studies. Always include the vital signs and total fluid input and output over the last shift if the patient is NPO or on a diuretic regimen. If daily weights are being recorded, they should be included here as well. Your physical examination write-up should include only pertinent positive and negative findings and any changes.

The assessment is your impression of the patient's problem or level of progress; it is a summary of how the patient is doing and what has changed from the previous day.

The plan is what you are going to do about each problem. It may include continuing, starting, or discontinuing a medication, laboratory tests to order, test results to obtain, consults to be called, and individual or family education.

The SOAP note is not supposed to be as complete as an admit note. Complete sentences are not necessary, and abbreviations are common. Remember that abbreviations, however, differ for each specialty! PND generally is an abbreviation for paroxysmal nocturnal dyspnea for most medical services, but for an ear, nose and throat service, PND is an abbreviation for postnasal drip. MS is commonly used for multiple sclerosis, but to a cardiologist, MS is mitral stenosis;to a pharmacist or anesthesiologist, MS is morphine sulfate;to an orthopedist or rheumatologist, MS is musculoskeletal.

The length of the note differs for each specialty as well. In general, medical notes tend to be long and surgical notes are short, but you will have to get a sense of what to do from the house staff team. Typically, medical students' notes are more detailed than the house staff note.

Always remember that the chart is a legal document. You should be confident in your presentations, but be conservative in the chart and present the facts clearly. Do not discuss other clinicians' opinions. Let the chart speak for itself.

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