类风湿关节炎英文病历.docVIP

Sample History and Physical Note Charting Plus? - Electronic Medical Records Note for John Doe on 4/18/02 - Chart 1124 Chief Complaint: This 26 year old male presents today for treatment of suspected rheumatoid arthritis. Associated signs and symptoms include aching, joint pain, and symmetrical joint swelling bilateral. Patient denies any previous history, related trauma or previous treatments for this condition. Condition has existed for 2 weeks. He indicates the problem location is the right hand and left hand. Patient indicates no modifying factors. Severity of condition is slowly worsening. Onset was unknown. Allergies: Patient admits allergies to aspirin resulting in GI upset, disorientation. Medication History: Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD. Past Medical History: Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of (+) appendectomy in 1989. Family History: Patient admits a family history of rheumatoid arthritis associated with maternal grandmother. Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. Review of Systems: Neurological: (+) paralysis Musculoskeletal: (+) joint pain (+) joint swelling (+) stiffness Cardiovascular: (+) ankle swelling Neurological: (-) numbness Musculoskeletal: (-) back pain (chronic) (-) decreased ROM (-) episodic weakness Cardiovascular: (-) chest pressure Respiratory: (-) breathing difficulties, respiratory symptoms (-) sleep apnea Physical Exam: BP Standing: 120/84 HR: 79 Temp: 98.6 Height: 5 ft. 8 in. Weight: 168 lbs. Patient is a 26 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus. Skin: No skin r