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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
S U B J E C T I V E
.NAME is a .AGE .GENDER who presents ***
O B J E C T I V E
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.
NaCl 0.9% 1,000 mL
Assessment & Plan:
Patient was seen and examined and plan was discussed with attending physician.
Electronically signed by:
On Call Intern Pager: 334-0024
On Call Senior Pager: 330-7125
Weekends, Weekdays after ~5 PM: Intern Phone x2362, Senior Phone x2216