IM WSU PROGRESS

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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 ***

Objective:
Visit Vital
.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