IM WSU PROGRESS
To contact provider: Daytime 7AM to 4PM: Nighttime 4PM to 7AM: Page latest IM medical staff note author If emergent, intern on-call 2362 1st call: Intern 2362 2nd call: Senior 2216 Wright State University Internal Medicine Miami Valley Hospital Internal Medicine Progress Note Patient Name: .NAME DOB: .BDAY MRN: .MRN Chief Complaint: .ADMITDX Subjective: .NAME is a .AGE .GENDER who presents *** O B J E C T I V E .VITALS Physical Exam: General: Awake, alert, no acute distress Neurological: Cranial nerves 2-12 grossly intact, no focal deficits Head: Normocephalic, atraumatic Eyes: Conjunctiva clear, PERRL, EOMI Ears: External ears normal to inspection Nose: No deformity, asymmetry, or inflammation Oral: Airway patent, lips normal without lesions Neck: Supple; trachea midline; no asymmetry, masses, or scars Chest: Normal respiratory effort, no use of accessory muscles Respiratory: Clear to auscultation without rhonchi, wheezes, or rales; symmetrical breath sounds; adequate oxygenation on ***. Heart: Regular rate and rhythm; no murmurs, rubs, gallops. Abdomen: Soft, obese, non-tender, non-distended; no guarding, rebound, or rigidity ***. Skin: Warm; normal color, texture, and turgor; no rashes or lesions Extremities: No clubbing, cyanosis, or edema. *** Normal muscle tone. Vascular: Bilateral palpable radial, DP, PT pulses. Psych: Alert and oriented x 3. Normal affect. Good insight. .MEDSCURRENT Continuous Infusions: NaCl 0.9% 1,000 mL Labs: .LABR24 Imaging Studies: .IMAGING Other Studies: .ECG Assessment & Plan: FEN: DVT Prophylaxis: GI Prophylaxis: CODE STATUS: Disposition: Patient was seen and examined and plan was discussed with attending physician. Electronically signed by: .SIGN Internal Medicine Pager: 937-334-0452 .DATE .TIME On Call Intern Pager: 334-0024 On Call Senior Pager: 330-7125 Weekends, Weekdays after ~5 PM: Intern Phone x2362, Senior Phone x2216
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