Demographics: (sentence format)

Work as a landscaper for the government and sale meat on the weekend.

No religion

Subjective:

CC:

“I had a vehicle accident”

H.P.I

-Patient stated he was experiencing headache when he got hit by a car, and his car end up hitting a pole.

-Hit head and shoulder

-wasn’t wearing seatguy.

-transported to the emergency room by an emergency

1. Onset (when did it start?)	Monday, last week Oct, 17 2016
2. Location (where is it located/ best felt?)	Mainly the left neck and shoulder -but not experiencing pain in left arm and fingers numbness. Had hard time moving the arm
3. Duration (How long does it last?)	Constant pain
4. Character (What is the pain like?)	Sometimes sharp
5. Aggravating factors (What triggers the pain?)	Movements
6. Alleviating factors (What makes it better?)	Rest and laying down in bed.
7. Radiation (Do you feel the pain moving anywhere else?)	Radiated to the whole left arm and fingers. Also sometimes experience pain in the left side of head.
8. Timing (When does it occur/recur? Any particular time of day?)	Throughout
Severity (Pain Scale – On a scale of 1 to 10, with 10 being the worst pain	8/10
9. You’ve ever felt, how would you rate this pain?)
Associated Symptoms	-Hear ringing in the ears (tinnitus). -Tight chest pain comes and go. -Shortness of breath -Had headache and backouts before -Frequent urination -Patient is currently receiving oxygen to help breathing -Drug was giving, before for hypertension -had an X-ray for the acciednet and there was no broken bone. -Costochoditis

PMH:

Medical

1. Childhood illnesses

Mumps, Wheeze before and still now, Up to date with immunization

2. Adult illnesses, including JAMTHREADS

-High blood pressure, was taking Panadol and Capoten (but patient was not compliant).

-Was on blood thinning

(NOTES: PLEASE USE THE INFORMATION TO GET DRUGS NAMES AND MORE PAST MEDICAL DETAILS)

-Stated he stopped smoking and drinking 2 years ago, and did remember when he started.

Medications given: at 2:40pm when her was admistered: Capoten 25mg

Nacl 0.9%

Panadol

Dezide 25 mg

-8/11/2016:

patiented admitted for Shortness of breathe and epigastric pain.

History of Hiatal Hernia

-Congested heart, and Hypertension

-pitting edema in both les

Medications given: Tramedol 50 mg

Amlodipinol

Nexium-20mg

EGK- mildl dilated heart

OB/GYN

Psychiatric:

Patient appeared to be depressed due to his family issues. Stated that he had a psychiatric elevation during his hospital stay.

(please refer to chart to make sure)

Surgical:

Past surgery done on his feet, due remove abscess. (PLEASE REFER TO CHART for more info)

Health Care Maintenance

(reefer to chart)