Virginia Oncology & Hematology, P

VIRGINIA ONCOLOGY &HEMATOLOGY, P.C.

Chief complaint:
Nausea, Vomiting, Fever, Chills, Mouth sores, Mucosal bleed, Diarrhea/ Constipation, Dyspnea, Cough feeling tired
Abdominal pain, back pain, leg edema , urinary complains, dizziness, night sweats PO intake,
Physical Exam: HEENT: Conjunctiva- Pale, sclera- uncteric, Mouth- T- hrush, Mucositis
o  Neck: Adenopathy, JVD
o  CVS- N.S.R. gallop, Murmur
o  Lungs : Clear bilaterally, Rhonchi, Crackles,
o  P/A: tenderness, Hepatomegaly, Splenomegaly, B.S.
o  MUCULOSKELATAL: spinal tenderness
o  CNS: alert, oriented X ,non-focal
o  Extremities: edema
o  INTEGUMENTARY: skin rash, petechiae
o  HEM: Bilateral axillary & Inguinal regions shows Adenopathy
TODAY’S ORDER:
o  LABS TO BE DRAWN ON RETURN VISIT:CBC, CMP, BMP, PT/PTT, Ferritin, Iron, TIBC______
Return visit MD______Months/weeks. Lab/Nurse______
Service Level______
M.D. Initials

Today’s Labs:

CBC, CMP, BMP,

Smear, PT, PTT, PSA, CEA, Ferritin, Iron, TIBC ______

Ht.______Wt.______

T_____P_____BP______

O2 SAT______%