Progress Note

Interval Events: ***

Subjective: ***

Exam

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– 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.

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Assessment

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  1. ***: ***

Bundle

– DVT: {IP DVT PROPHYLAXIS IP:22062}

– FEN: ***

– K, Mg: ***

– Emergency contact: @[email protected]

– @[email protected]

Prepared with the assistance of [INSERT YOUR NAME HERE] via remote participation.