Admission Note

Nota preenchida

Admission Note

Patient Identification: adult presenting with worsening cough and fever.

History of Present Illness:
Reports three days of cough and feeling feverish, with increased fatigue. The cough is dry and has gradually worsened. No known sick contact is reported. Fluids and rest have provided limited relief. The patient remains able to drink and walk around the home, though usual activity is reduced.

No prior similar episode or recent imaging is reported. The patient denies chest pain, shortness of breath at rest, and coughing blood. Review of systems is notable for cough, subjective fever, and fatigue; gastrointestinal symptoms are denied.

Past Medical History:
- No chronic conditions reported.

Medications:
- No regular medications reported.

Allergies:
- No known drug allergies reported.

Family History:
- No relevant family history reported.

Social History:
- No tobacco or recreational substance use reported; lives with family.

Physical Examination:
- Vital signs: Temperature mildly elevated; other values not recorded.
- General: Tired appearing, alert, no acute distress.
- Respiratory: Mild scattered crackles; no increased work of breathing.
- Cardiovascular: Regular rhythm.

Investigations:
- No completed investigations reported.

Assessment & Plan:
adult admitted for evaluation of acute cough and fever, with infection among the considerations.

1) Cough and fever
- Monitor respiratory status and hydration.
- Obtain indicated diagnostic testing and tailor treatment to results.
- Escalate evaluation for worsening breathing or clinical status.

Best Practices:
- Code status, lines and tubes, prophylaxis, diet, and activity not specified.

Caso ilustrativo com dados de paciente inventados. Não é um registro real de paciente nem orientação clínica. Revise cada nota à luz da sua própria consulta.

Fatos clínicos por trás da nota

Estrutura reutilizável do modelo

<b>Admission Note</b>

[Date and time if mentioned]

<b>Patient Identification:</b> [Patient name, age, gender, with a history of..., presenting with...]

<b>History of Present Illness:</b>
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems in a sentence]

<b>Past Medical History:</b>
(hyphenated list)

<b>Medications:</b>
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Metformin 500 mg oral BID)

<b>Allergies:</b>
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

<b>Family History:</b>
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- (e.g., Mother: breast cancer)

<b>Social History:</b>
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]

<b>Physical Examination:</b>
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [Physical exam findings and/or mental status exam findings] (Format as "System: Exam findings", one system per line. Specify anatomical location if relevant)

<b>Investigations:</b>
(hyphenated list)
- [Investigation results with units] (Only include completed investigations, otherwise leave blank. All planned or ordered investigations should be included under Plan)

<b>Assessment & Plan:</b>
(Do not fabricate the assessment and plan unless mentioned in the source material. Use medical terminology if appropriate.)
[One-sentence patient summary including age, sex, and primary diagnosis]

#) [Assessment as a numbered item if mentioned]
- [Hyphenated list with each corresponding plan item on a new line if mentioned]

#) Best Practices (if mentioned)
- [Code status]
- [Lines and tubes]
- [DVT prophylaxis]
- [Diet]
- [Activity]

(ensure numbers are listed for each issue)