Infectious Disease Initial Consult

Infectious Diseases Consult Note
 
Attending: @@@
 
Reason for consult: @@@
 
HPI:
 

ROS
 
12-point review of system is negative unless stated above.
 
PMHx/PSHx: 
as above

SHx: 
@@@

Allergies:
@@@

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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:

@@@
 
 
ACTIVE MEDS: |ACTIVE MEDICATIONS|
 
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ASSESSMENT:

@@@
 
 
 
RECOMMENDATIONS:
 
- @@@ Will continue to follow
- @@@ ID signing off
- Call back for additional questions
- Case discussed with attending Dr. @@@