Centro templates:
Consultation template:
The patient was in their baseline health being able to ambulate by themselves, independent
ADLs without baseline angina or dyspnea until …, when
The patient denies any headaches, weakness, parasthesia, falls, changes in gait, changes in
vision, coryza, sore throat, red eyes, swelling in the neck, changes in voice, chest pain,
orthopnea, PND, cough, shortness of breath, wheezing, nausea, vomiting, diarrhea or
constipation, abdominal pain, melena, hematochezia, dysuria, hematuria, calf tenderness, new
joint pain, skin lesions, fever, chills, night sweats, weight loss or changes in appetite.
On examination the patient appears in no acute distress.
HEENT: no pale conjunctiva or scleral icterus, no cervical lymphadenopathy, normal oral
mucosa with … dentition.
Chest: no clubbing or cyanosis, good air entry bilaterally without crackles or wheezes, resonant
to percussion, no CVA/spinal tenderness
CVS: JVP ~ … cm ASA, S1, S2, no S3/S4, murmur, apical impulse normal, … Pedal edema;
peripheral pulses: radial and posterior tibial 2+ equal.
Abdomen: normal bowel sounds, no evidence of chronic liver disease, …. Scars, no tenderness
to light or deep palpation, no rebound tenderness, no masses or appreciable
hepatosplenomegaly.
Lower extremity: no calf tenderness or ulcers
Neurological:
CNII-XII grossly normal (PERL, normal EOM, normal masseter, grossly normal facial sensation
and muscle movements, grossly normal hearing, normal articulation, normal trapezius strength,
normal tongue protrusion without deviation of the uvula)
Motor: UE: 5/5 symmetrical: grip, wrist flexion, wrist extension, elbow flexion, elbow extension,
shoulder abduction; LE: 5/5 symmetrical: plantar flexion, dorsiflexion, knee extension, knee
flexion, hip flexion, hip abduction.
Sensory: normal sensation to touch
DTR: 2+ symmetrical: brachioradialis, biceps, patella, ankle
Babinski: negative bilaterally
normal rapid alternating movement, gait not assessed.
Skin: no worrisome lesions of back, chest, abdomen, arms or legs.
Invest:
Hgb = (MCV =
) BL = ; WBC = (ANC =
Na = K =
HCO3- =
Cr = BL = :
; Ur:
Ca = ; Mg = ; Phos =
bili t = ; ALT =; ALP = ; Alb =
INR = ; PTT =
TSH =
hsTropT =
V = pH =
/pCO2 =
(BL = )/
) BL = ; Plat: BL =
; glucose / CBGM:
Lact.
CXR:
EKG:
TTE (Date): LVEF:
PASP = , LAD =
, no significant valvulopathy, no reported wall motion abnormalities,
Micro:
Blood Culture:
Urine culture:
I/P:
VTE prophylaxis:
Level of care:
Disposition
Progress Note Template:
Is a
year-old male with a history of
admitted with
The patient reports ….
The patient denies fever, night sweats, chills, chest pain, dyspnea, no nausea vomiting or
diarrhea, constipation, abdominal pain, dysuria or pain in the calves.
On examination: patient appears in no acute distress
VS: BP
; HR
(reg); T =
o
C; O2 sat =
(RA); RR
HEENT: normal oral mucosa,
Chest: no cyanosis, good airway entry bilaterally without crackles or wheezes
CVS: JVP
cm ASA, S1, S2, no S3/S4, murmur,
Pedal edema
Abdomen: normal bowel sounds, no tenderness to light or deep palpation, no rebound
tenderness, no masses or appreciable hepatosplenomegaly.
Lower extremity: no calf tenderness
Invest:
Hgb = (MCV =
) stable; WBC = (ANC =
Na = K =
HCO3- =
Cr = BL:
; Ur:
Ca, Mg, Phos normal
Liver enzymes in normal range
V = pH =
/pCO2 =
(BL)/
Lact.
CXR:
Micro:
Blood Culture:
Urine culture:
) stable ; Plat: BL
; glucose / CBGM:
I/P:
VTE prophylaxis:
Level of care:
Disposition:
-Arif Awan
PGY-2 (2014-2015)