3.60## ##|| 1 ##Done by##Berger|Martinez|| 2 ##Last name##|| 3 ##First name##|| 4 ##D##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|| 5 ##M##- Clear all -|- Back -|1|2|3|4|5|6|7|8|9|10|11|12|| 6 ##Y##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|| 7 ##Weight (Kg)##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|.|| 8 ##Height (cm)##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|.|| 9 ##T°##- Clear all -|- Back -|36.|37.|38.|39.|40.|0|1|2|3|4|5|6|7|8|9|| 10 ##Resp rate##- Clear all -|- Back -|10|12|14|16|18|20|22|24|26|28|30|32|34|36|38|40|| 11 ##Systolic BP##- Clear all -|- Back -|100|105|110|115|120|125|130|135|140|145|150|155|160|165|170|175|180|| 12 ##Diastolic BP##- Clear all -|- Back -|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120|| 13 ##Pulse##- Clear all -|- Back -|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120|125|130|135|140|145|150|155|160|| 14 ##O2 Sat (%)##- Clear all -|- Back -|100|99|98|97|96|95|94|93|92|91|90|89|88|87|86|85|| 15 ##Age##|| 16 ##Gen##- Back -|<==|,|NAD|weak|cachectic|dehydrated|febrile|diaphoretic|somnolent|pale|| 17 ##Habitus##- Back -|<==|,|plethoric|obese|cachectic|lean|athletic|| 18 ##Muscular##- Back -|<==|,|generalized|atrophic|located|upper limb|lower limb|normal|well preserved|L|R|| 19 ##Skin##- Back -|<==|,|erythema|maculopapular|rash|located|trunk|upper limb|lower limb|face|vesicles|papule|ecchymosis|graze|wound|forearm|thigh|foot|hand|| 20 ##ECG##- Back -|<==|,|AF|NSR|normal repolarization|no ST changes|2° AVB|Axis = °|| 21 ##Thyroid##- Back -|<==|,|not palpated|size|normal|increased|mass|lobe|L|R|bruit|| 22 ##Lymphadenopathy##- Back -|<==|,|adenopathy|submandibular|L|R|cm of diameter|retroauricular|cervical|supraclavicular|submaxillary|node|inguinal|axillary|fixed|mobilee|tender|| 23 ##Breast##- Back -|<==|,|palpation|normal|lump|upper|lower|L|R|mammary gland|erythema|| 24 ##Skeletal##- Back -|<==|,|kyphosis|lordosis|scoliosis|spinal column|joint|painful|on range of motion|at rest|flexion|active|passive|heat|erythema|tumefaction|| 25 ##Oropharynx##- Back -|<==|,|throat|benign|erythematous|tonsil|hypertrophy|purulent|petechiae|poor oral hygiene|| 26 ##Ears##- Back -|<==|,|fluid|external auditory canal|calm|normal|erythematous|retrotympanic collection|not visualized|| 27 ##Psychiatric##- Back -|<==|,|calm|agitated|anxious|depressed|aggressive|normal|| 28 ##Cranial nerves##- Back -|<==|,|EOMI|normal|PERRL|hearing|facial nerve|sensation|soft palate|glossopharyngeal n.|hypoglossal n.|accessory n.|visual field|symmetrical|| 29 ##Tone##- Back -|<==|,|rigidity|tremor|flaccid|normal|hypotonic|hypertonic|neck supple|symmetrical|grasp|Brudzinski|| 30 ##Strength##<==|- Back -|,|strength intact|deficit|lower limb|upper limb|on the L|on the R|paretic|normal|asymmetric|Mingazini|| 31 ##Reflexes##- Back -|<==|,|reflex|patellar|achilles|bicipital|decreased|intact|hypertonic|absent|brisk and symmetrical|normal|symmetrical|| 32 ##Coordination##- Back -|<==|,|finger-nose-finger|heel-knee-shin|diadocokinesis|ambulation|sensation|normal|symmetrical|fluid|| 33 ##Sensation##- Back -|<==|,|preserved|absent|decreased|in the distribution of|sensation|vibration|deficit|uper limb|lower limb|on the L|on the R|foot|normal|symmetrical|| 34 ##Skin color##- Back -|<==|,|pale|cyanotic|plethoric|central|peripheral|normal|| 35 ##Edema##- Back -|<==|,|lower extremity edema|in sock distribution|to the knees|to thigh|presacral|pitting|normal|symmetrical|bilateral|| 36 ##Jugular veins##- Back -|<==|,|jugular v.|JVD|distended|not visualized|to mid-neck|canon waves|CVP|jugular venous pressure at __ cmH2O|hepato-jugular reflux|positive|negative|normal|| 37 ##Veins##- Back -|<==|,|varixes|bilateral|symmetrical|ulcer|varicose|important|thrombosis|normal|negative Homan sign|no cord palpable|tender|diameter|thigh|calf|on the L|on the R|no|| 38 ##Pulse 2##- Back -|<==|,|radial|femoral|popliteal|posterior tibial|dorsal pedis|pedal|slow|strong|abdominal aorta|carotid|++/++|+/+|normal|thready|absent|cap refill < 3sec|| 39 ##Bruits##- Back -|<==|,|carotid|left|right|bilateral|femoral|abdominal aorta|no|| 40 ##SBP##- Back -|- Clear all -|90|95|100|105|110|115|120|125|130|135|140|145|150|155|160|165|170|175|180|| 41 ##DBP##- Back -|- Clear all -|50|55|60|65|70|75|80|85|90|95|100|105|110|115|120|| 42 ##Heart rate##- Clear all -|- Back -|60|65|70|75|80|85|90|95|100|105|110|115|120|| 43 ##Rhythm##- Back -|<==|,|regular|gallop|irregular||,|premature beat|tachycardic|bradycardic|| 44 ##PMI##- Back -|<==|,|present in the 6th intercostal space|in the mid-clavicular line|not palpable|diffuse|thrill|heave|| 45 ##Heart auscult.##- Back -|<==|,|systolic|diastolic|radiating to the carotids|2/6|galop|no murmurs|normal S1+S2|rub|murmur|pulmonar|carotid|mitral|tricuspid|no|loudest at the |apex|axilla|LUSB|| 46 ##Respirations##- Clear all -|- Back -|10|12|14|16|18|20|22|24|26|28|30|32|34|36|38|40|| 47 ##O2 Sat (%) 2##- Clear all -|- Back -|100|99|98|97|96|95|94|93|92|91|90|89|88|87|86|85|| 48 ##Peak Flow##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|| 49 ##Sputum##- Back -|<==|,|dry cough|barking cough|loose cough|hemoptysis|hematemesis|greenish sputum|chronic cough|| 50 ##Pulm auscultation##- Back -|<==|,|bruit|symmetrical|rale|crackles|egophony|at bilateral bases|inspiratory+expiratory|prolonged expiration|decreased breath sounds|tubolar breath sounds|dullness|stridor|ronchi|rub|whispered pectoriloquy|bronchial breath sounds|| 51 ##Percussion##- Back -|<==|,|dullness|symmetrical|at the right base|at the left base|| 52 ##Inspection##- Back -|<==|,|distended|scaphoid|flat|protuberant|scar|laparotomy|cholecystectomy|appendicectomy|inguinal herniorrhaphy|nevus araneus|hysterectomy|caesarean|stretch marks|ascites|| 53 ##Auscultation##- Back -|<==|,|normal bowel sounds|normal|tone|increased|decreased|metallic|absent|abdominal aortic bruit|| 54 ##Palpation##- Back -|<==|,|non-tender, FROM|no|guarding|soft|localized|flank|epigastric|hypogastric|right iliac|left iliac|RUQ|LUQ|periumbilical|right side|left side|suprapubic|negative psoas sign|negative Murphy sign|pain located in|| 55 ##CVA##- Back -|<==|,|FROM|no CVAT|CVAT|left|right|| 56 ##Liver##- Back -|<==|,|nonpalpable|at costal margin|hepatomegaly|splenomegaly|hard|soft|nodular|smooth|liver span|| 57 ##Rectal##- Back -|<==|,|nontender|tender|rectal vault|full|empty|stool|hard|soft|brown|normal|red|black|hematochezia|melena|normal rectal tone|hemorrhoid|prostate|increased|median furrow present|| 58 ##Detailed exam##- Back -|<==|,|purulence|wound|deformation|bony palpation|erythema|warmth|ecchymosis|mobilie|nontender|tender|fluctuant mass|palpation|walk|F/E: 0 - 0 - 0|| 59 ##PMD##Parcker|Mason|Arlington|| 60 ##Attending##Mason|Decoster|| 61 ##Chief Complaint##¢3¢Infectious|fever|cough|dehydratation|¢3¢Abdominal|vomiting|anorexia|abdominal pain|¢3¢Cardiology|chest pain|dyspnea|weakness|¢12¢Trauma|fall|wound|head|arm|hand|hips|leg|knee|ankel|foot|left|right|- Clear all -|- Back -|- Space -|,|diminished|general state|since|day|| 62 ##History of Present Illness##- Space -|<-|- Back -|,|Patient is __ years old,|with history of|starting from|day|pain|since|radiating to|burning|dyspnea|diarrhea|vomiting|thoracic|abdominal|diabetes|HTN|treated by|CHF|| 63 ##Past Medical History##<==|DMII|HTN|CHF|Arthritis|Osteoporosis|Alcohol abuse|Angina|COPD|Appendectomy|Infarct|Renal insufficiency|Tobacco use|Cholecystectomy|AF|Hypercholesterolemia|| 64 ##Medications##¢36¢Dose|1|1.5|2|2.5|5|10|15|20|25|50|75|100|250|500|750|1000|mcg|mg|g|ml|iv|im|ir|sc|1-0-0|0-0-1|1-0-1|1-1-1|q 4h|q 6h|q 12h|1t/d|2t/d|3t/d|4t/d|¢3¢Cardiology (b)|Aspirin|Lasix|Spironolactone|¢2¢Infectious (b)|Amoxicillin|Ceftriaxone|¢3¢Analgesia (b)|Tylenol|Ibuprofen|Morphine|<==|- Space -|- Back -|- Clear -|| 65 ##Family history##- Back -|<==|,|brother|sister|father|mother|family|deceased|infarct|cancer|diabetes|hypercholesterolemia|obesity|| 66 ##Habits and Risk Factors##- Back -|<==|,|active|sedentary|diabetes|High blood pressure|able to|climb|walk|flights|blocks|| 67 ##Tobacco##- Clear all -|- Back -|,|PPD|cigarettes|quit|one year ago|years ago|1|2|3|4|5|10|15|20|25|| 68 ##Alcohol##- Clear all -|- Back -|,|beers|wine|mixed drinks|never|occasionnally|quit|| 69 ##Allergy##- Clear all -|- Back -|<---|,|no allergies|allergic to|PCN|antibiotics|iodine|asthma|hay fever|| 70 ##Social##- Clear all -|- Back -|<==|,|live alone|married|single|home health|bedbound|ECF resident|| 71 ##General##- Back -|<==|,|good usual health|fever|failure to thrive|dehydrated|| 72 ##Cardiovascular##- Back -|<==|,|dyspnea|chest pain|intermittent claudication|lower extremity edema|varicose veins|nocturia|orthopnea|palpitations|angina|since|worse|| 73 ##Respiratory##- Back -|<==|,|cough|productive|greenish|nonproductive|chronic|since|worse|dyspnea|with minimal exertion|sputum|| 74 ##GI##- Back -|<==|,|abdominal pain|epigastric|RUQ|LUQ|RLQ|LLQ|suprapubic|since|no|crampy|diarrhea|nausea|melena|hematochezia|dyspepsia|dysphagia|| 75 ##GU##- Back -|<==|,|dysuria|oliguria|hematuria|dirty urine|suprapubic pain|urinary hesitancy|since|| 76 ##Endocrine##- Back -|<==|,|fatigue|tachycardia|cold intolerance|transient|polydipsia|menstruation|menopause|menorrhagia|metrorrhagia|amenorrhea|hypoglycemia|since|| 77 ##Musculoskeletal##- Back -|<==|,|arthralgia|lumbago|neck pain|range of motion|limited|chronic|since|| 78 ##Neurologic##- Back -|<==|,|insomnia|weakness|numbness|paresthesias|dysarthria|blindness|disorientation|amnesia|since|| 79 ##Labs##¢12¢Numbers|- Back -((1))|0|1|2|3|4|5|6|7|8|9|.|¢4¢Urine| &- U prot=| &- U nitrit=| &- U Hb=| &- U Leu=|- Back -|<==|,| &- Na=| &- K=| &- Urea=| &- Creat=| &- Na= &- K= &- BUN= &- Creat=| &- WBC=| &- Hgb=| &- Plt=| &- CRP=| &- WBC= &- Hgb= &- Plt= &- CRP=| &- Cholestasis| &- Liver enzymes| &- Pancreatic enzymes|| 80 ##ABG##¢12¢Numbers|- Back -((1))|0|1|2|3|4|5|6|7|8|9|.|- Back -|<==| &- pH=| &- PO2=| &- PCO2=| &- HCO3=| &- O2Sat=| &- BE=| &- pH= &- pO2= &- pCO2= &- HCO3= &- BE=|| 81 ##Microbiology##- Back -|<==|,|Blood culture|positive|negative|pending|Urine culture|Staphylococcus|Smear|Wound culture|catheter|| 82 ##Radiographic films##<==|- Back -|,|infiltrate|basal|on the left|on the right|bilateral|pulmonary edema|diffuse|in the lung fields|pleural effusion|pneumothorax|atelectasis|dilatation|small bowel|colic|air bronchograms|cardiomegaly|| 83 ##CT+MRI##- Back -|<==|,|mass|hemorrhage|tumour|metastasis|fracture|stranding|| 84 ##Echo+U/S##- Back -|<==|,|mass|cyst|cholelithiasis|biliary dilatation|cholecystitis|pancreas|normal|liver|metastasis|kidney|hydronephrosis|ureterolithiasis|| 85 ##Other tests##- Back -|<==|,|US-Doppler|Nuclear medicine|Abdomen|Doppler|MRI|Colonoscopy|UGI|Barium enema|Enteroclysis|Gastrografin transit|Gastroscopy|| 86 ##Assessment##Appendicitis|Pneumonia|CHF|Constipation|Gastroenteritis|| 87 ##Problem##HTN|COPD|Cholecystitis|pain|Abdominal|Dyspnea|decompensated|Diabetes|CHF|Renal failure|Hyperkaliaemia|Hypokalemia|Constipation|Fever|LE edema|Diarrhea|Vomiting|Pneumonia|| 88 ##Subjective##- Back -|<==|,|pain|increased|decreased|stable|resolved|improved|worse|chest pain|dyspnea|no|continued|nausea|vomiting|diarrhea|headache|insomnia|distress|erythema|cough|| 89 ##Objective##- Back -|<==|,|T°= |P=|BP= |pulm ausc|LE edema|improved|worse|decreased|increased|stable|persistent|palpation|pain|rale|wet rale|normal|no|| 90 ##Tests##¢14¢Numbers|[[[ Labs ]]]|[[[ ABG ]]]|- Back -((2))|0|1|2|3|4|5|6|7|8|9|.|¢11¢Labs|[[[ Numbers ]]]|- Back -((1))|<==| &- Na=| &- K=| &- Creat=| &- WBC=| &- CRP=| &- Hgb=| &- WBC= &- Hgb= &- Plt=| &- Na= &- K= &- BUN= &- Creat=|¢9¢ABG|[[[ Numbers ]]]((1))|<==((2))|- Back -((3))| &- pH=| &- pO2=| &- pCO2=| &- HCO3=| &- BE=| &- pH= &- pO2= &- pCO2= &- HCO3= &- BE=|- Back -|<==((3))|,|Abdomen|CT Scan|Abd US|LE dopplers|mass|diameter|infiltrate|Urinary sediment|| 91 ##Meds##500 mg|<==|,|Acetaminophen|1-1-1|1-0-1|1-0-0|/d|100 mg|NS 2000ml/d|| 92 ##Other##surgery|<==|,|chemotherapy|| 93 ##Plan##- Back -|<==|,|discharge|tomorrow|as tolerated|out of bed|advance diet|hydrate|correct eletrolytes|antibiotics|continue|stop|no|on an empty stomach|| 94 ##Room N°##¢10¢Room N° (b)|320|321|322|323|324|325|326|327|328|329|- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|D|W|LD|LW|RD|RW|| 95 ##BMI##|| 96 ##Free 1##|| 97 ##Free 2##|| 98 ##To do##,|WBC tomorrow|call lab|discharge summary|call PMD|AM labs|advance diet|drugs...|increase|decrease|control|BMP|| 99 ##Free 3##|| 100##Edit 0##|| 101##Edit 1##|| 102##Edit 2##|| 103##Edit 3##|| 104##Edit 4##|| 105##Edit 5##|| 106##Edit 6##|| 107##Edit 7##|| 108##Edit 8##|| 109##Edit 9##|| 110##Edit 10##|| 111##Edit 11##|| 112##Edit 12##|| 113##Edit 13##|| 114##Edit 14##|| 115##Edit 15##|| 116##Edit 16##|| 117##Edit 17##|| 118##Edit 18##|| 119##Edit 19##|| 120##Last name ID##|| 121##First name ID##|| 122##Day ID##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|| 123##Month ID##- Clear all -|- Back -|1|2|3|4|5|6|7|8|9|10|11|12|| 124##Year ID##- Clear all -|- Back -|0|1|2|3|4|5|6|7|8|9|| 125##Profession##|| 126##Civil state##|| 127##Origin##|| 128##Confession##|| 129##Address##|| 130##City##|| 131##Postal code##|| 132##Phone##|| 133##Contact##|| 134##Insurance##|| 135##Ins n°##|| 136##Ins class##|| 137##Other 1##|| 138##Other 2##|| 139##Other 3##|| 140##Send 2##I need to see you|I need your help about|Hello|The meeting is at __.__ am|patient|| 141##Window 1##|| 142##Window 2##|| 143##Window 3##|| 144##Window 4##|| 145##Window 5##|| 146##Window 6##|| 147##Window 7##|| 148##Window 8##|| 149##Window 9##|| 150##Window 10##|| 151##Window 11##|| 152##Window 12##|| 153##Window 13##|| 154##Window 14##|| 155##Window 15##|| 156##Window 16##|| 157##Window 17##|| 158##Window 18##|| 159##Window 19##|| 160##Window 20##|| 161##Window 21##|| 162##Window 22##|| 163##Window 23##|| 164##Window 24##|| 165##Window 25##|| 166##Window 26##|| 167##Window 27##|| 168##Window 28##|| 169##Window 29##|| 170##Window 30##|| 171##Window 31##|| 172##Window 32##|| 173##Window 33##|| 174##Window 34##|| 175##Window 35##|| 176##Window 36##|| 177##Window 37##|| 178##Window 38##|| 179##Window 39##|| 180##Window 40##|| 181##Window 41##|| 182##Window 42##|| 183##Window 43##|| 184##Window 44##|| 185##Window 45##|| 186##Window 46##|| 187##Window 47##|| 188##Window 48##|| 189##Window 49##|| 190##Window 50##|| 191##Window 51##|| 192##Window 52##|| 193##Window 53##|| 194##Window 54##|| 195##Window 55##|| 196##Window 56##|| 197##Window 57##|| 198##Quick Notes##¢10¢Number|0|1|2|3|4|5|6|7|8|9|¢4¢Copy,Cut,Paste|- Space -|- Copy -|- Cut -|- Paste -|- Back -|<==|T°=|P=|BP=|BP=w|BP= __ / __|Resp=|Pulse= &- BP= __ / __ &- Resp= &- T°=|RCP= &- WBC= &- Hgb=|Na= &- K= &- BUN= &- Creat=|| 199##Window 59##|| 200##Chart N°##|| 201##Chart 2##|| #Labels#|Birth date|Admission date|Icons|Daily Summary|To Do List|||||||||||||||||||Hospital Course|Disch. date|Admission Summary|Test Summary|Patient ID|Birth date|Age| #Plain text#|Patient's name|||||||||||||||||||Course|Problems|Daily Summary|Problem List|To Do List|Exam Summary|History|Admission Testing|Radiology|Inpatient Tests|Differential diagnosis||Hospital Course|Current meds|Plan|NL| |LW|RW|RD|LD|W|D|R|L|Alone|Out|IV Therapy|Unstable|Stable|Check back|Septic|Critical|Mrs|Mr|Mrs|Mr|Problem N°|Patient|||||||||||||||||||To do|Problems|S: Day|S: Problems|S: To do|S: Tests|S: Admission|S: Out letter|S: Orders|S:Edit 1|S : Edit 2|Patient ID|Send|Mail manager|Server|S: All patients|S: Manager|blank|Big|Thin|Small|Lady 1|Lady 2|Man 1|Man 2||||||||||°|kg|cm|/min|%|||||||Start|Stop|Done|D|P|Empty|Now|Solved|Birth|Now|Yesterday|Diagnosis|Other|Att|To do|Tests|Adm|Usual|Labs|ABG|Micro|Rx|CT+MRI|Echo|Other exams|General information|Room n°|N°|Name|Attending|Diagnosis|Record n°|Mr/Mrs|Last|First|Birth date|Age|Weight|Admission|Icon|Room number|Icon number|Patient|Attending|Dr|Out Letter|Prob N°|Past History|Main List|Active|State|Prob|Urgent !|To do|Location|Department||||||||||||||S: Graph|Quick notes||||||||| #Date#|Sunday|Monday|Tuesday|Wednesday|Thursday|Friday|Saturday|January|February|March|April|May|June|July|August|September|October|November|December|days|months|years|weeks|| ee