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Admission Orders - Practice |
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Using the following history and physical, please write the admission orders. When you finish compare your orders to the following set of orders.
Before you proceed print out a blank orders sheet here.
NOTE: You will need to have Adobe Acrobat Reader installed to view this file. Use the print button on the Adobe Acrobat Reader menu bar NOT the print button on the browser menu bar. (See Example)
Background Information:
CC: This 54 year old male presents with a cough
HPI: The patient has noticed a severe cough for one week. It is productive of green phlegm. He has noted fevers to 102 degrees.
PMH: Never been hospitalized. Long-standing hypertension and increased cholesterol.
MEDS: Lipitor - 10 mg po qd and Dyazide - one tablet po qd
Allergies: None Smoking: 1 ppd Alcohol: None Family History: Negative Social History: Married, 2 children, works as a carpenter. ROS: Otherwise negative.
Physical Exam: Adult male with a cough and mild shortness of breath. Vitals: BP. - 140/80 Pulse - 90 Temp - 39 degrees C
HEENT - Dry mucous membranes Neck - supple Lungs - dullness to percussion on left chest, crackles in left lower lobe. Heart - Normal S1 and S2, no S3, S4 or mummur Abdoman - soft, good bowls sounds, non-tender, no organomegaly Genital/Rectal - no testicular masses, no prostate Neuro - normal reflexes, no lateralizing weakness
Problem List:
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