1
Working From Home During the Pandemic
Dirck Mitchell
Professor Brazil
November 29, 2021
Working From Home During the Pandemic
I. Introduction
A. Working remotely during the pandemic saved many lives.
B. At the height of the pandemic, when infection rates were soaring, working remotely offered a safe alternative to ensure that the company operations were not affected and that the health of staff was not compromised.
1. Remote working ensured the safety of employees.
2. Working from home has had its challenges.
3. Solutions to the challenges of working from home.
II. Body
1. Remote working ensured the safety of employees. (1. Michaels & Wagner, 2020)
a. By working from employees minimized the risk of COVID-19 infections.
b. Working remotely ensured that employees' mental health was protected
because they did not have to worry about getting infected.
2. Working from home has had its challenges. (2. Aczel et al., 2021)
a. Challenges in employee collaboration.
b. Communication challenges among employees.
3. Solutions to the challenges of working from home. (3. White, 2021)
a. Tools such as Zoom can help overcome collaboration challenges.
b. Using project management tools in place of emails for communication.
III. Conclusion
A) Working from home ensured many employees did not contract COVID-19. However, as a new experience, it still had its challenges, but these can be overcome by using relevant tools to ensure the experience simulates in person working.
B) Working from home also ensured that employees could continue with their responsibilities without the fear of contracting COVID-19 and risking their families.
C) There are valid concerns about working from home, but solutions to these teething problems. Accommodations can also be made for those who prefer to work in-person to resume working from the office.
References
Michaels, D., & Wagner, G. R. (2020). Occupational Safety and Health
Administration (OSHA) and worker safety during the COVID-19 pandemic. Jama, 324(14), 1389-1390.
Aczel, B., Kovacs, M., van der Lippe, T., & Szaszi, B. (2021). Researchers working
from home: Benefits and challenges. PloS one, 16(3), e0249127.
White, G. (2021). BURNOUT: Helping Employees Avoid & Weather the Challenges
of Working From Home. Professional Safety, 66(5), 16-19.
Admission History and Physical
ANP 652: Robin McLinn
Patient Name: A.S. DOB: 03/15/1992
Provider: ACNP Student Robin McLinn RM#: ED #14
ADM: 07/14/2020 Patient Type: Tele Inpatient
CHIEF COMPLAINT: Chief Complaint: “I have had a fever for 3 days with diarrhea starting today, I feel really tired and can’t catch my breath. I had a COVID 19 test come back positive from an outside lab”
RELIABILITY: History obtained from the patient, and EMR.
HISTORY OF PRESENT ILLNESS: This is a 28-year-old Hispanic male that was brought to the ED by his girlfriend. Patient has had a 3+ day stated fever accompanied by diarrhea and shortness of breath. Patient was at a family party a three weeks ago, where he later learned an aunt had tested positive for COVID-19. Patient started having a cough so decided to get tested by an outside lab 7 days ago. Stated he was informed he was positive yesterday. Patient has been mildly symptomatic with a cough up until 3 days ago where he began having chills and became febrile. He now reports diarrhea x2 today, difficulty breathing, and productive cough. He is currently in the ED. Girlfriend is retrieving testing confirmation from apartment. FULL CODE
PAST MEDICAL HISTORY: Obesity, chicken pox (4yrs old), broken leg 2010, depression treated by PCP.
PAST SURGICAL HISTORY: Appendectomy 2016, Tonsillectomy/Adenoidectomy approximately 23yrs ago.
SOCIAL HISTORY: Single. Lives in apartment with girlfriend. Denies tobacco, illicit drugs, or vaping. Drinks socially 4-5 drinks/month. Employed at Amazon full time.
FAMILY HISTORY: Father has HTN, DMII, obesity. Mother had breast cancer 2015 both alive in their late 50’s. Two brothers in good health, no children.
( 1 )
( This study source was downloaded by 100000800518114 from CourseHero.com on 12-15-2021 07:43:31 GMT -06:00 ) ( https://www.coursehero.com/file/65712889/H-and-P-2docx/ )
MEDICATIONS: Celexa dose unknown daily for depression. Melatonin 5mg as needed for sleep at night.
ALLERGIES: Seasonal, shellfish
REVIEW OF SYSTEMS:
CONSTITUTIONAL: SOB, chills, febrile, HEAD AND NECK: Reports headache
CARDIOVASCULAR: denies chest pain or palpitation, reports diaphoresis RESPIRATORY: Reports difficulty breathing, productive cough, denies hemopytosis GASTROINTNTESTINAL: Reports diarrhea x 2, denies blood in stools, reports nausea GENTINOURINARY: Denies urgency, denies foul odor
MUSCULOSKELETAL: Reports joint and muscle pain NEUROLOGIC: Reports weakness, Denies syncope, dizziness PSYCHOLOGIC: Reports depression IMMUNOLOGIC/ALLERGY: Denies bruising or bleeding INTEGUMENT: Denies skin changes or rash
PHYSICAL EXAMINATION:
VITAL SIGNS: T: 38.1 C oral, BP: 159/79, P: 107, RR: 28, PO: 90 on 7L Pain 2
GENERAL: Normal appearance, obese, nontoxic appearance, otherwise healthy
HEENT: no JVD, Normocephalic, trachea midline, PERRLA, mucous membranes moist and pink, sclera white.
NECK: No masses, no nodules, no trachea deviation
CHEST: AP Diameter 2:1, Lung sounds have crackles, asymmetrical vocal resonance, abnormal breath sounds.
HEART: S1 S2, no murmers, no heaves, EKG 12 lead Sinus tachycardia at 107 bpm ABDOMEN: Soft, denies tenderness, bowel sounds present
NEUROLOGIC: Alert and oriented x 3, PERRLA, answers questions appropriately EXTREMITIES: Palpable pulses, no wounds or lesions, no edema
GENERAL: alert and oriented x 3
DIAGNOSITIC EVALUATION:
Chest X-Ray: Bilateral alveolar opacities with ground glass appearance. Ground glass opacities are consistent with COVID-19 (Jacobi, Chung, Bernheim, & Eber, 2020).
LABS: 07/14/2020
CRP: 33.1 mg/L 1.0 mg/L and 3.0 mg/L
ALT: 57
AST: 62
WBC 14.0
LYM: 1.20
Albumin: 1.9
Urea: 0.835
Bicarbonate: 25 mEq/L
Ferritin: 340.3
PCO2: 51.0 FiO2: 30% P/F Ratio: 170 mmHg
ASSESSMENT:
1. Hypoxia (R09.02): Patient presented to the ER with a complaint of shortness of breath which is still present. Patient is on 5 Liters of oxygen via nasal cannula. This may be a result of COVID-19 or Pneumonia.
2. Shortness of Breath (R06.02): Related to hypoxemia
3. Fever, unspecified (R50.09): Patient has reported a fever over the last few days, was controlling with acetaminophen prior to arriving at ER.
4. Tachycardia, unspecified (R00.0): Can be a normal response to fever
5. Cough (R05): Inflammation and fluid in the alveoli will produce a cough, likely from COVID-19 or pneumonia
6. History of depression (Z86.59): Controlled by PCP with Celexa, denies depression at this time.
7. Obesity, unspecified (E66.9): Patient has a history of obesity
DIFFERENTIAL DIAGNOSIS:
1. COVID-19 (U07.1): This patient has a reported positive COVID-19 test from an outside lab, new test being run to confirm a diagnosis. COVID-19 has quickly become a global pandemic infecting 5.8 million people globally (Michienzi, & Badowski, 2020).
Symptoms are fever, chills, SOB, headache, nausea or vomiting, and diarrhea to name a few.
2. Pneumonia (J12.89): Possible co-infection. COVID-19 and pneumonia have similar symptoms. Pneumonia can be both viral or bacterial which cannot be predicted without testing (Lhommet, Garot, Grammatico-Guillon, Jourdannaud, Asfar, Faisy,... & Lanotte, 2020).
3. Coccidioidomycosis (B38.9) Unlikely, however symptoms are similar with fever, shortness of breath, headache, and fatigue (Sarkisyan, 2019).
Plan:
1. Admit to observation unit with continuous cardiac monitoring
2. Regular diet as tolerated
3. Monitor O2 saturation, titrate as needed, report changes
4. Pulmonology consult
5. Start COVID-19 protocol (IV Ascorbic acid, Zinc gluconate, dexamethasone)
6. Treat with broad spectrum antibiotic until Pneumonia ruled out.
7. Celexa 10 mg daily (home medication)
Additional labs ordered:
Type and Screen- For Possible Infusion Convalescent Plasma Legionella urine- R/O pneumonia
Strep pneumonia urine- R/O pneumonia Sputum Culture- R/O pneumonia
Cocci IgG- R/O coccidioidomycosis Cocci IgM- R/O coccidioidomycosis D-dimer
Geriatric Specific
COVID-19 has quickly become a global pandemic infecting 5.8 million people globally (Michienzi, & Badowski, 2020). There is a heightened risk to the elderly with regards to COVID-19 due to their weakened immune system. The CDC reports 8 out of 10 COVID-19
deaths are in adults 65 years and older (CDC, 2020). There is a generally a higher risk for a severe illness in patients over the age of 50 which climbs up to severe illness in patients 85 and older who contract COVID-19 (CDC, 2020). The public is reminded daily to limit interactions with people, wear a mask, and stay home as much as possible, clean and disinfect surfaces, and wash hands often, to protect against COVID-19.
There are a variety of abnormalities found in the labs of patients who test positive for COVID-19. Current studies have found a positive result on the impact of ascorbic acid and zinc gluconate and dexamethasone, in reducing the symptoms in patients diagnosed with COVID-19 (NIH, 2020). Studies are also showing Remdesivir, a broad spectrum anti-viral drug to have good results in decreasing the duration of COVID-19.
References
Centers for Disease Control and Prevention, (2020). Older adult’s coronavirus disease.
Retrieved from https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/older-adults.html
Jacobi, A., Chung, M., Bernheim, A., & Eber, C. (2020). Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Clinical imaging, 64, 35–42. https://doi.org/10.1016/j.clinimag.2020.04.001
Lhommet, C., Garot, D., Grammatico-Guillon, L., Jourdannaud, C., Asfar, P., Faisy, C., ... & Lanotte, P. (2020). Predicting the microbial cause of community-acquired pneumonia: can physicians or a data-driven method differentiate viral from bacterial pneumonia at patient presentation?. BMC pulmonary medicine, 20(1), 1-9.
Michienzi, S. M., & Badowski, M. E. (2020). Can vitamins and/or supplements provide hope against coronavirus?. Drugs in Context, 9.
Sarkisyan, D. (2019). Acute Pulmonary Coccidioidomycosis. Proceedings of UCLA Health, 23.
U.S. National Library of Medicine, (2020). Coronavirus 2019(COVID-19) Using ascorbic acid and zinc supplementation. Retrieved from https://clinicaltrials.gov/ct2/show/NCT04342728
Wilkerson, R. G., Adler, J. D., Shah, N. G., & Brown, R. (2020). Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19. The American journal of emergency medicine, S0735-6757(20)30390-9. Advance online publication. https://doi.org/10.1016/j.ajem.2020.05.044
Admission History and Physical
ANP 652: Robin McLinn
Patient Name: A.S. DOB: 03/15/1992
Provider: ACNP Student Robin McLinn RM#: ED #14
ADM: 07/14/2020 Patient Type: Tele Inpatient
CHIEF COMPLAINT: Chief Complaint: “I have had a fever for 3 days with diarrhea starting today, I feel really tired and can’t catch my breath. I had a COVID 19 test come back positive from an outside lab”
RELIABILITY: History obtained from the patient, and EMR.
HISTORY OF PRESENT ILLNESS: This is a 28-year-old Hispanic male that was brought to the ED by his girlfriend. Patient has had a 3+ day stated fever accompanied by diarrhea and shortness of breath. Patient was at a family party a three weeks ago, where he later learned an aunt had tested positive for COVID-19. Patient started having a cough so decided to get tested by an outside lab 7 days ago. Stated he was informed he was positive yesterday. Patient has been mildly symptomatic with a cough up until 3 days ago where he began having chills and became febrile. He now reports diarrhea x2 today, difficulty breathing, and productive cough. He is currently in the ED. Girlfriend is retrieving testing confirmation from apartment. FULL CODE
PAST MEDICAL HISTORY: Obesity, chicken pox (4yrs old), broken leg 2010, depression treated by PCP.
PAST SURGICAL HISTORY: Appendectomy 2016, Tonsillectomy/Adenoidectomy approximately 23yrs ago.
SOCIAL HISTORY: Single. Lives in apartment with girlfriend. Denies tobacco, illicit drugs, or vaping. Drinks socially 4-5 drinks/month. Employed at Amazon full time.
FAMILY HISTORY: Father has HTN, DMII, obesity. Mother had breast cancer 2015 both alive in their late 50’s. Two brothers in good health, no children.
( 1 )
( This study source was downloaded by 100000800518114 from CourseHero.com on 12-15-2021 07:43:31 GMT -06:00 ) ( https://www.coursehero.com/file/65712889/H-and-P-2docx/ )
MEDICATIONS: Celexa dose unknown daily for depression. Melatonin 5mg as needed for sleep at night.
ALLERGIES: Seasonal, shellfish
REVIEW OF SYSTEMS:
CONSTITUTIONAL: SOB, chills, febrile, HEAD AND NECK: Reports headache
CARDIOVASCULAR: denies chest pain or palpitation, reports diaphoresis RESPIRATORY: Reports difficulty breathing, productive cough, denies hemopytosis GASTROINTNTESTINAL: Reports diarrhea x 2, denies blood in stools, reports nausea GENTINOURINARY: Denies urgency, denies foul odor
MUSCULOSKELETAL: Reports joint and muscle pain NEUROLOGIC: Reports weakness, Denies syncope, dizziness PSYCHOLOGIC: Reports depression IMMUNOLOGIC/ALLERGY: Denies bruising or bleeding INTEGUMENT: Denies skin changes or rash
PHYSICAL EXAMINATION:
VITAL SIGNS: T: 38.1 C oral, BP: 159/79, P: 107, RR: 28, PO: 90 on 7L Pain 2
GENERAL: Normal appearance, obese, nontoxic appearance, otherwise healthy
HEENT: no JVD, Normocephalic, trachea midline, PERRLA, mucous membranes moist and pink, sclera white.
NECK: No masses, no nodules, no trachea deviation
CHEST: AP Diameter 2:1, Lung sounds have crackles, asymmetrical vocal resonance, abnormal breath sounds.
HEART: S1 S2, no murmers, no heaves, EKG 12 lead Sinus tachycardia at 107 bpm ABDOMEN: Soft, denies tenderness, bowel sounds present
NEUROLOGIC: Alert and oriented x 3, PERRLA, answers questions appropriately EXTREMITIES: Palpable pulses, no wounds or lesions, no edema
GENERAL: alert and oriented x 3
DIAGNOSITIC EVALUATION:
Chest X-Ray: Bilateral alveolar opacities with ground glass appearance. Ground glass opacities are consistent with COVID-19 (Jacobi, Chung, Bernheim, & Eber, 2020).
LABS: 07/14/2020
CRP: 33.1 mg/L 1.0 mg/L and 3.0 mg/L
ALT: 57
AST: 62
WBC 14.0
LYM: 1.20
Albumin: 1.9
Urea: 0.835
Bicarbonate: 25 mEq/L
Ferritin: 340.3
PCO2: 51.0 FiO2: 30% P/F Ratio: 170 mmHg
ASSESSMENT:
1. Hypoxia (R09.02): Patient presented to the ER with a complaint of shortness of breath which is still present. Patient is on 5 Liters of oxygen via nasal cannula. This may be a result of COVID-19 or Pneumonia.
2. Shortness of Breath (R06.02): Related to hypoxemia
3. Fever, unspecified (R50.09): Patient has reported a fever over the last few days, was controlling with acetaminophen prior to arriving at ER.
4. Tachycardia, unspecified (R00.0): Can be a normal response to fever
5. Cough (R05): Inflammation and fluid in the alveoli will produce a cough, likely from COVID-19 or pneumonia
6. History of depression (Z86.59): Controlled by PCP with Celexa, denies depression at this time.
7. Obesity, unspecified (E66.9): Patient has a history of obesity
DIFFERENTIAL DIAGNOSIS:
1. COVID-19 (U07.1): This patient has a reported positive COVID-19 test from an outside lab, new test being run to confirm a diagnosis. COVID-19 has quickly become a global pandemic infecting 5.8 million people globally (Michienzi, & Badowski, 2020).
Symptoms are fever, chills, SOB, headache, nausea or vomiting, and diarrhea to name a few.
2. Pneumonia (J12.89): Possible co-infection. COVID-19 and pneumonia have similar symptoms. Pneumonia can be both viral or bacterial which cannot be predicted without testing (Lhommet, Garot, Grammatico-Guillon, Jourdannaud, Asfar, Faisy,... & Lanotte, 2020).
3. Coccidioidomycosis (B38.9) Unlikely, however symptoms are similar with fever, shortness of breath, headache, and fatigue (Sarkisyan, 2019).
Plan:
1. Admit to observation unit with continuous cardiac monitoring
2. Regular diet as tolerated
3. Monitor O2 saturation, titrate as needed, report changes
4. Pulmonology consult
5. Start COVID-19 protocol (IV Ascorbic acid, Zinc gluconate, dexamethasone)
6. Treat with broad spectrum antibiotic until Pneumonia ruled out.
7. Celexa 10 mg daily (home medication)
Additional labs ordered:
Type and Screen- For Possible Infusion Convalescent Plasma Legionella urine- R/O pneumonia
Strep pneumonia urine- R/O pneumonia Sputum Culture- R/O pneumonia
Cocci IgG- R/O coccidioidomycosis Cocci IgM- R/O coccidioidomycosis D-dimer
Geriatric Specific
COVID-19 has quickly become a global pandemic infecting 5.8 million people globally (Michienzi, & Badowski, 2020). There is a heightened risk to the elderly with regards to COVID-19 due to their weakened immune system. The CDC reports 8 out of 10 COVID-19
deaths are in adults 65 years and older (CDC, 2020). There is a generally a higher risk for a severe illness in patients over the age of 50 which climbs up to severe illness in patients 85 and older who contract COVID-19 (CDC, 2020). The public is reminded daily to limit interactions with people, wear a mask, and stay home as much as possible, clean and disinfect surfaces, and wash hands often, to protect against COVID-19.
There are a variety of abnormalities found in the labs of patients who test positive for COVID-19. Current studies have found a positive result on the impact of ascorbic acid and zinc gluconate and dexamethasone, in reducing the symptoms in patients diagnosed with COVID-19 (NIH, 2020). Studies are also showing Remdesivir, a broad spectrum anti-viral drug to have good results in decreasing the duration of COVID-19.
References
Centers for Disease Control and Prevention, (2020). Older adult’s coronavirus disease.
Retrieved from https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-
precautions/older-adults.html
Jacobi, A., Chung, M., Bernheim, A., & Eber, C. (2020). Portable chest X-ray in coronavirus disease-19 (COVID-19): A pictorial review. Clinical imaging, 64, 35–42. https://doi.org/10.1016/j.clinimag.2020.04.001
Lhommet, C., Garot, D., Grammatico-Guillon, L., Jourdannaud, C., Asfar, P., Faisy, C., ... & Lanotte, P. (2020). Predicting the microbial cause of community-acquired pneumonia: can physicians or a data-driven method differentiate viral from bacterial pneumonia at patient presentation?. BMC pulmonary medicine, 20(1), 1-9.
Michienzi, S. M., & Badowski, M. E. (2020). Can vitamins and/or supplements provide hope against coronavirus?. Drugs in Context, 9.
Sarkisyan, D. (2019). Acute Pulmonary Coccidioidomycosis. Proceedings of UCLA Health, 23.
U.S. National Library of Medicine, (2020). Coronavirus 2019(COVID-19) Using ascorbic acid and zinc supplementation. Retrieved from https://clinicaltrials.gov/ct2/show/NCT04342728
Wilkerson, R. G., Adler, J. D., Shah, N. G., & Brown, R. (2020). Silent hypoxia: A harbinger of clinical deterioration in patients with COVID-19. The American journal of emergency medicine, S0735-6757(20)30390-9. Advance online publication. https://doi.org/10.1016/j.ajem.2020.05.044
History and Physical Note
12 points
Criteria Description
History and Physical Note (Chief Complaint, HPI, Patient History, Home Medications, Review of Systems, Vital Signs, Physical Exam, Test Results)
5. Target
12 points
The history and physical note is thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
10.8 points
The history and physical note is provided with appropriate details and support.
3. Approaching
9.6 points
The history and physical note is present, but only minimal detail or support is provided.
2. Insufficient
6 points
The history and physical note is incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The history and physical note is not included.
Assessment and Clinical Impressions
12 points
Criteria Description
Assessment and Clinical Impressions (Identification of Three Differential Diagnoses, List of Acute and Chronic Diagnoses, List of Diagnoses and Conditions in Priority Order)
5. Target
12 points
The assessment and clinical impressions are thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
10.8 points
The assessment and clinical impressions are provided with appropriate details and support.
3. Approaching
9.6 points
The assessment and clinical impressions are present, but only minimal detail or support is provided.
2. Insufficient
6 points
The assessment and clinical impressions are incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The assessment and clinical impressions are not included.
Plan Component Management and Criteria
12 points
Criteria Description
Plan Component Management and Criteria Incorporation (Interventions, Disposition, Expected Outcomes, Health Education, and Case Summary)
5. Target
12 points
The plan component management and plan criteria incorporation are thoroughly explored and clearly explained with relevant details and support.
4. Acceptable
10.8 points
The plan component management and plan criteria incorporation are provided with appropriate details and support.
3. Approaching
9.6 points
The plan component management and plan criteria incorporation are present, but only minimal detail or support is provided.
2. Insufficient
6 points
The plan component management and plan criteria incorporation are incomplete or otherwise deficient.
1. Unsatisfactory
0 points
The plan component management and plan criteria incorporation are not included.
Peer-Reviewed Articles
6 points
Criteria Description
Peer-Reviewed Articles
5. Target
6 points
Three peer-reviewed articles are included.
4. Acceptable
5.4 points
N/A
3. Approaching
4.8 points
N/A
2. Insufficient
3 points
Fewer than three peer-reviewed articles are provided.
1. Unsatisfactory
0 points
Three peer-reviewed articles are not included.
Mechanics of Writing
6 points
Criteria Description
Includes spelling, capitalization, punctuation, grammar, language use, sentence structure, etc.
5. Target
6 points
No mechanical errors are present. Skilled control of language choice and sentence structure are used throughout.
4. Acceptable
5.4 points
Few mechanical errors are present. Suitable language choice and sentence structure are used.
3. Approaching
4.8 points
Occasional mechanical errors are present. Language choice is generally appropriate. Varied sentence structure is attempted.
2. Insufficient
3 points
Frequent and repetitive mechanical errors are present. Inconsistencies in language choice or sentence structure are recurrent.
1. Unsatisfactory
0 points
Errors in grammar or syntax are pervasive and impede meaning. Incorrect language choice or sentence structure errors are found throughout.
Format/Documentation
12 points
Criteria Description
Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.
5. Target
12 points
No errors in formatting or documentation are present. Selectivity in the use of direct quotations and synthesis of sources is demonstrated.
4. Acceptable
10.8 points
Appropriate format and documentation are used with only minor errors.
3. Approaching
9.6 points
Appropriate format and documentation are used, although there are some obvious errors.
2. Insufficient
6 points
Appropriate format is attempted, but some elements are missing. Frequent errors in documentation of sources are evident.
1. Unsatisfactory
0 points
Appropriate format is not used. No documentation of sources is provided.
Total 60 points
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History and Physical Note Template
Chief Complaint or Reason for Consult: Why the patient is seeking medical care or the reason
you have been consulted.
History of Present Illness (HPI): History of present illness is the "Who, What, When, Where,
Why, How, How Long" section used to document the patient's story related to the chief
complaint or consult.
Past Medical History: A list of all medical diagnoses (include pertinent information such as a
new diagnosis). Identify the length of the diagnosis with either year or longevity.
Past Surgical History: A list of all surgeries. Be sure to include the date of the surgery.
Family History: First-degree pedigree medical diagnoses—be sure to include age and cause of
death of family members.
Social History: A synopsis of work, tobacco, alcohol, drug use, marital status, residence, travel,
functional status, and surrogate/advanced directives.
Allergies: A list of medication or food allergies and the type of reaction the patient experiences
when exposed to the foods or medications.
Home Medications: List all home medications and the dosage in milligrams and frequency.
Document adherence, including prn/over-the-counter and how often the patient takes prn
medications.
Hospital Medications: List the name, milligrams, frequency, and route if you are seeing the
patient after being admitted.
Review of Systems: Review of symptoms (told by the patient or family) but organized by
system. Must have 12 systems with at least 2 pertinent +/-
• CONSTITUTIONAL: These are the patient's answers about general constitutional signs or symptoms. Some examples may be fatigue, exercise intolerance, fever, weakness, and impaired ability to carry out
functions of daily living.
• EYES: These are the patient’s answers about signs or symptoms that may include the use of glasses, eye discharge, eyes itching, tearing or pain, spots or floaters, blurred or doubled vision, twitching, light
sensitivity, swelling around the eyes or lids, and visual disturbances.
• EARS, NOSE, and THROAT: These are the patient's answers about signs or symptoms, including sensitivity to noise, ear pain, ringing in the ears, vertigo, feeling of fullness in the ears, ear wax, and
abnormalities. It could include nosebleed, postnasal drip, frequent sneezing, frequent nasal drainage,
impaired ability to smell, sinus pain, difficulty breathing, or history of sinus infection and treatment. For
the throat and mouth: sore throat, current or recurrent mouth lesions, teeth sensitivity, bleeding gums,
history of hoarseness, change in voice quality, difficulty in swallowing or inability to taste.
• CARDIOVASCULAR: These are answers by the patient regarding signs and symptoms which may include chest pain, tightness, numbness, palpitations, heart murmurs, irregular pulse, color changes in the
fingers or toes, edema, leg pain when walking.
2
• RESPIRATORY: These are the patient's answers about signs or symptoms of the respiratory system. Some examples may be cough, phlegm, chest pain on deep inhalation, wheezing, shortness of breath,
difficulty breathing.
• GASTROINTESTINAL: These are patient’s answers about signs or symptoms of the GI system and include such things as indigestion or pain associated with eating, burning sensation in the esophagus,
frequent nausea or vomiting, abdominal swelling, changes in bowel habits or stool characteristics, such as
diarrhea or constipation.
• GENITOURINARY: These are the patient's answers about signs or symptoms of the genitourinary system. Some examples include painful urination, urine characteristics, urinary patterns, hesitance, flank
pain, decreased or increased output, dribbling, incontinence, frequency at night, genital sores, erectile
dysfunction, irregular menses, toilet training, or bedwetting.
• MUSCULOSKELETAL: These are the patient's answers about signs or symptoms of the musculoskeletal system. Examples include muscle cramps, twitching or pain, limitations on walking, running, or
participation in sports, joint swelling, redness or pain, joint deformities, stiffness, and noise with joint
movement.
• INTEGUMENTARY: These are the patient's answers about signs or symptoms of the skin. Some examples may be itching, rash, skin reactions to hot and cold, changes of scars, moles, sores, lesions, nail
color or texture, breast pain, tenderness or swelling, breast lumps, and history of nipple discharge or
changes.
• NEUROLOGICAL: These are the patient's answers about signs or symptoms of the neurologic system. Examples include numbness, tingling, dizziness, fainting or unconsciousness, seizures or convulsions,
memory loss, attention difficulties, hallucinations, disorientation, speech or language dysfunction, inability
to concentrate, sensory disturbances, motor disturbances, including gait, balance, and coordination, tremor,
or paralysis.
• PSYCHIATRIC: These are the patient's answers about signs or symptoms of the psychiatric system. Some examples include depression, excessive worrying, stress, suicidal thoughts, persistent sadness, anxiety, loss
of pleasure from usual activities, loss of energy, physical problems that do not respond to treatment,
restlessness, irritability, and excessive mood swings.
• ENDOCRINE: These are the patient's answers about signs or symptoms of the endocrine system. Some examples may be blood sugar readings at home, sudden changes in height or weight, increased appetite or
thirst, intolerance to heat or cold, and changes in hair distribution or skin pigment.
• HEMATOLOGIC/LYMPHATIC: These are the patient's answers about signs or symptoms of the hematologic/lymphatic system. Examples include easy bruising, fevers which come and go, swollen glands,
night sweats, and unusual bleeding.
• ALLERGIC/IMMUNOLOGIC: These are the patient's answers about signs or symptoms of allergic/immunologic issues. Examples include answers about allergies to medication, foods or other
substances, hives or itching, frequent sneezing, chronic or clear postnasal drip, conjunctivitis, history of
chronic infection, etc.
Physical Exam: What you identify as you assess the patient.
• GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress.
• VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal
cannula, weight, and BMI.
• HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good
dentition, no lesions. Tympanic membranes are clear.
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• NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness.
• CHEST: Symmetric. Nontender to palpation.
• LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.
• HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.
• BREASTS: Symmetrical. No skin or nipple retractions. No nipple discharges or masses.
• ABDOMEN: Soft, flat, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass.
• GENITOURINARY: [Male]. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended
bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal.
• GENITOURINARY: [Female]. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus
are normal.
• RECTAL: [Male]. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance.
• RECTAL: [Female]. Normal sphincter tone. No masses or tenderness.
• EXTREMITIES: No cyanosis, clubbing, or edema.
• NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact.
• PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate mood and affect.
• SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Address surgical wounds and drains.
• LYMPHATICS: No cervical, axillary, or groin adenopathy is noted.
Laboratory and Radiology Results: List all data available when seeing the patient's normal and
abnormal results. Include all of the CBC and electrolytes (all elements tell a story).
Assessment: (Provide three references)
• Differential Diagnoses: A differential diagnosis are potential diagnoses related to the chief complaint and assessment. Provide a rationale for the working diagnosis which is
one of the differential diagnoses. Include the ICD codes. List at least three working
diagnoses related to the admission or consult and identify one as being the primary
diagnosis until ruled out.
• Acute and Chronic Medical Conditions: What needs to be addressed while admitted, in order of priority.
Treatment Plan: (Provide three references)
What orders are you starting? What medications with dose and frequency? What consults?
Education topics? Discharge plan?
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Geriatric Considerations:
Based on the age, address any differences in the treatment if the patient was younger or older.
References: List references in APA format.
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