Infectious Disease FOllOW UP

ID FOLLOW UP NOTE

Fellow: Dr. Weiland
 
Subjective/Interval Hx:
- no acute events 

-
 
========================================
 
OBJECTIVE:
 
VITAL SIGNS                                                                     
   T: |TEMP|                                                                   
   P: |PULSE|                                                                  
   R: |RESP|                                                                   
  BP: |BP|                                                                     
  HT: |PATIENT HEIGHT|                                                        
  WT: |WT|  
  PULSE OXIMETER: |PULSE OX|      
 
EXAM:
GEN: NAD
HEENT: anicteric, OP clear, moist MM
NECK: supple, no LAD
CV: RRR, no murmurs, rubs or gallops
CHEST: CTAB
ABD: soft, NT/ND, BS present in 4 quadrants 
EXT: normal ROM, no edema
SKIN: no rashes or lesions
NEURO: AAOx3, grossly nonfocal

LABS: 

CBC
|HS:SCL1-CBC-AFTER10/14-5;10Y|
 
CHEMISTRY
|LAB-SODIUM;1;1Y|
|LAB-POTASSIUM;1;1Y|
|LAB-CO2;1;1Y|
|LAB-CHLORIDE;1;1Y|
|LAB-BUN;1;1Y|
|LAB-CREATININE;1;1Y|
|LAB-GLUCOSE;1;1Y|
|LAB-CALCIUM;1;1Y|
|LAB-PHOSPHORUS;1;1Y|
|LAB-ALBUMIN;1;1Y|
|LAB-ALT;1;1Y|
|LAB-AST;1;1Y|
 
MICRO:
 
ANTIMICROBIALS:
 
IMAGING:reviewed
 
ACTIVE MEDICAIONS: 

|ACTIVE MEDICATIONS|
 
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ASSESSMENT:
 
 
 
RECOMMENDATIONS:

- Will continue to follow 
- Thank you for allowing us to participate in this patient's care. 
- ID signing off, call back for additional questions
- Case discussed with attending Dr. @@@