Progress Note
Interval Events: ***
Subjective: ***
Exam
@VSRANGES@
@IOBRIEF@
– Gen: NAD
– HEENT: MMM, PERRL, oropharynx non-erythematous, no cervical or supraclavicular LAD
– CV: RRR, no m/r/g, JVP ***
– Pulm: CTAB, no wheezes, rhonchi, or rales
– Abd: Soft, NTND, NABS, no rebound or guarding
– Ext/skin: WWP, no rashes, no edema
– Neuro: AOx3, CNII-XII intact, strength 5/5 and sensation intact to light touch in all extremities
Meds, Labs and Imaging reviewed in Epic and notably commented on below.
@FISHBONEBMP@
@FISHBONECBC@
Assessment
@BRIEFSUMMARY@
- ***: ***
Bundle
– DVT: {IP DVT PROPHYLAXIS IP:22062}
– FEN: ***
– K, Mg: ***
– Emergency contact: @RREMERCONTACT@
– @RRCODESTATUS@
Prepared with the assistance of [INSERT YOUR NAME HERE] via remote participation.