ID CONSULT

REASON FOR CONSULTATION

ID Attending is Dr. Castro
HISTORY OF PRESENT ILLNESS
This is a
ID is being consulted for
Pt has been __
REVIEW OF SYSTEMS
Negative except for HPI.
PAST MEDICAL HISTORY
PAST SURGICAL HISTORY
FAMILY HISTORY
ALLERGIES
NKDA
SOCIAL HISTORY
CURRENT ANTIBIOTICS
PREVIOUS ANTIBIOTICS
PHYSICAL EXAMINATION
VITAL SIGNS
GENERAL APPEARANCE
HEENT Normocephalic and atraumatic, PERRLA, EOMI, no oral lesions.
NECK Supple, no thyroid enlargement.
LUNGS CTAB, non-labored breathing
HEART RRR, Normal S1-S2, no murmurs rubs or gallops.
ABDOMEN Soft. Non-distended. No hepatosplenomegaly, masses, or tenderness. Bowel sounds+ x4.
SKIN
LYMPH No enlarged nodes palpable in neck, axillae, groin.
EXTREMITIES No peripheral edema. Peripheral pulses 2+ in all 4 extremities.
NEURO Strength equal bilaterally in upper and lower extremities. Cranial nerves grossly intact.
PSYCH AAOx3. Calm and cooperative. Not anxious.
LABORATORY DATA
Recent laboratory, microbiology, and imaging studies reviewed in Cerner.
CBC
BMP
GFR
MICROBIOLOGY DATA
Blood Cx
RADIOLOGY DATA

IMPRESSION
PROBLEM LIST
RECOMMENDATIONS
Patient discussed with Dr. Castro, ID Attending.