NKDHC Progress Note

Date:
Attending: Will King M.D. F.A.C.P.

I/O:

UOP:

Time:
Service: Nephrology

Temp:

BP:

Pulse:

All meds have been reviewed

CC/HPI:

Meds:

Labs:

Diagnostic:

+ eyes
+ ENT-neck + hem/lymph
+ endocrine
ROS: + fever/chills/headache
+ dyspnea/cough/hemoptysis
+ chest pain/palpitations/edema
+ N/V/D
+ M/S
+ oliguria/dysuria/difficulty/hematuria + skin
+ neuro
+ psych
all other were systems reviewed and are negative
Allergies with adverse reaction, if known:
EXAM:
GA:
Eyes:
ENMT:
Neck:
Resp:
CV:
GI:
LN:
M/S
Skin:
Neuro:
Psych:

well nourished
sclera aniecteric
nl ear/nose
nl JVP
nl resp effort
nl rhythm
soft
nl cervical
no joint effusion
no rash/ulcer
nl cranial nerves
no asterixis
nl affect

malnourished
jaundice
nl hearing
nl tracheal position
nl breathing sounds
no M/R/G
NT/no masses
cervical
nl ROM
no masses/induration
nl sensation
+ asterixis
AAOX3

Assessment:
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ATTENDING SIGNATURE: _______________________________________

Will King M.D. F.A.C.P.

NAD
PERRL
nl teeth/gums
nl thyroid
nl percussion
no edema
no organmegaly
axillary
nl gait

nl muscle strength
tremor

in distress
EOMI
dry mouth
no masses
nl palpitation
+ edema
nl BS
groin
no clubbing/cyanosis
nl reflexes
obtunded

Plan:
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Place patient sticker here