Edema HISTORY_LIST ***** HISTORY OF PRESENT ILLNESS duration of edema localized edema generalized edema associated pain swelling erythema time of day exacerbation by menses exacerbated by position food allergies environmental allergies ***** HISTORY CHRONIC DISEASE SYSTEMIC DISORDERS liver dz. heart dz. renal dz. thyroid dz. DVT venous insufficiency varicose veins malnutrition SURGERY PREVIOUS HOSPITALIZATIONS past trauma past surgery PREVIOUS TESTS cardiac testing chest x-rays venous cutdowns central lines SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine intravenous drug abuse ALLERGY medications foods seasonal FAMILY HISTORY heart dz. diabetes MEDS_LAB_TESTS ***** MEDS estrogen steroids vasodilators cardiac drugs furosemide ***** LAB Electrolytes BUN Creatnine CBC LFT Iron Studies ***** TESTS CXR ECG REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge REVIEW_OF_SYSTEMS_3 OB/GYN metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries sagittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty in fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts hospitalization for, psychiatric problems personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia PHYSICAL_EVAL_1 VITALS BP Postural BP Pulse Temp Heart rate NECK JVD at 45( carotid pulse amplitude carotid pulse duration PHYSICAL_EVAL_2 CHEST breath sounds crackles wheezes dullness to percussion displaced PMI atrial fibrillation S3 gallop rubs ABDOMEN hepatojugular reflex ascites hepatomegaly splenomegaly abdominal distention fluid wave shifting dullness EXTREMITIES pitting edema non-pitting edema extent of edema varicose veins erythema skin warm to the touch mottled brown discoloration of ankles increased circumference tenderness Homan's sign pulses cyanosis clubbing needle marks sclerotic veins scars DIFF_DIAGNOSIS Venous or lymphatic obstruction Chronic venous insufficiency CHF Cirrhosis Renal disease Nephrotic syndrome Hypothyroidism Drug associated edema Hypoalbuminemia due to, malabsorption enteropathies Anemia Angioedema Cellulitis