## WSU IM CONSULT

***Consultation Note
Consultation:

.NAME
.BDAY
.MRN

.DATE

Consultation requested by: ***

Reason for Consultation: ***

IMPRESSION:
***

RECOMMENDATIONS:
***

----------------------------------------------------
HPI***

ROS:
Const: No  {CONST:31234}
Eyes: No {EYES:31235}
Ent: No  {ENT:31236}
Resp:No  {RESP:31237}
Card:No  {CARD:13219}
GI: No {GI:13220}
GU:No  {GU:31240}
MS: No {MS:31241}
H-L:No  {H-L:31242}
Endo: No {ENDO:31243}
Skin:No  {SKIN:31244}
Neuro:No  {NEURO:31245}
Imm: No  {IMM:31246}
Psyc: No {PSYC:31247}   

A L L E R G I E S
.ALLERGY

M E D I C A T I O N S
.MEDSCURRENT

M E D I C A L 
.PMH

S U R G I C A L
.SURGICALHX

F A M I L Y
.FAMHX

S O C I A L 
.SOC 

V I T A L S
.VITALSCURRENT

P H Y I S I C A L
GENERAL: Awake, oriented, appears non-toxic
ENMT: Atraumatic, normocephalic, oral mucosa pink and moist, airway patent, no pharyngeal edema or erythema. External ears and nose normal. 
EYES: Conjunctiva clear, PERRL, EOMI
NECK: Supple, non-tender, no masses, trachea midline. Thyroid nontender, no gross palpable mass(es)
LYMPH: No cervical LAD. No preauricular LAD.
CARDIOVASCULAR: Normal heart rate, Normal rhythm, No murmurs, rubs, or gallops. Pedal pulses palpable. No lower extremity edema.  
PULMONARY/CHEST: Normal respiratory effort. Clear to auscultation, no rhonchi, wheezes, or rales. Symmetrical breath sounds. 
ABDOMINAL: Non-distended, normal bowel sounds, soft, non-tender. No hepatosplenomegaly. No gross mass (es) palpated. No hernias visible.
NEUROLOGIC: CN II-XII grossly intact. Sensation intact to light touch in upper and lower extremities. Strength 5/5 in upper and lower extremities. 
MUSCULOSKELETAL: No clubbing or cyanosis. Normal muscle tone. 
SKIN: Warm, Dry, No erythema, No rash
PSYCH: Alert and oriented x 3. Normal affect. Good insight. 

L A B S
.LABR24

I M A G I N G
.IMAGING

.SIGN