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Internal Medicine Patient Progress Note

The document is a clinical note detailing the evolution of a patient in internal medicine, including vital signs and physical examination findings. The patient is conscious and oriented, with no significant symptoms but presents with paleness and febrile spikes while undergoing antibiotic treatment. Laboratory results are mentioned, indicating the need for ongoing monitoring and evaluation.

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4 views1 page

Internal Medicine Patient Progress Note

The document is a clinical note detailing the evolution of a patient in internal medicine, including vital signs and physical examination findings. The patient is conscious and oriented, with no significant symptoms but presents with paleness and febrile spikes while undergoing antibiotic treatment. Laboratory results are mentioned, indicating the need for ongoing monitoring and evaluation.

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Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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NOTE OF EVOLUTION OF INTERNAL MEDICINE

NAME DEL PATIENT:


FECHA:
CAMA:
TIME:
VITAL SIGNS Patient of sex...........of..........years old, who is going through
his/her day ...
FC: of hospital stay, and that has the following
diagnostics
FR: 1)
T/A: 2)
T°: 3)

Patient male/female who refers asymptomatic refers (signs


subjective examples; pain, nausea, etc.) Tolerating orally, with evacuations
and present diuresis. Patient reports ……………………………………………….
O: Patient from apparent age to chronological age, conscious, oriented in
time, place and person, cooperator. Paleness of skin and mucous membranes, with adequate
hydration.
Skull without depressions or exostosis, cylindrical neck with central trachea
movable, without visible or palpable adenomegaly, or jugular engorgement,
symmetric carotid pulses without alterations.
Normal line thorax, with adequate ventilatory movements, vibrations
normal vocal sounds, clear pulmonary from the apices to the pulmonary bases,
generalized vesicular murmur, adequate rhythmic heart sounds
intensity without the presence of murmurs. Globular abdomen due to panniculus
fatty, with normoactive peristalsis, soft, compressible and not painful to the touch
palpation, without palpable visceromegaly, dullness in colonic frame. Giordanos
positives.
Eutrophic, euthermic, symmetrical upper extremities, with capillary refill.
2 seconds, no edema, with preserved strength.
The patient has the following laboratory results today
(Put more relevant or abnormal results). Patient who is still
with febrile spikes, evolving sluggishly to treatment with
antibiotic therapy.

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