<p><strong>Date:</strong></p><p><strong>Time:</strong></p><p><br data-cke-filler="true"></p><p><strong>Consulting Physician:</strong></p><p><strong>Reason of Consult:</strong></p><p><strong>HPI:</strong></p><p><strong>Past Medical History:</strong></p><p><strong>Surgical History:</strong></p><p><strong>Family History:</strong></p><p><strong>Social History:</strong></p><p><strong>Current Medications:</strong></p><p><strong>Allergies:</strong></p><p><strong>Review of Systems:</strong> All systems were reviewed and was found negative except the above in HPI.</p><p><strong>Physical Exam:</strong></p><p><strong>Vital signs:</strong></p><p><strong>Constitutional:</strong> Well developed well-nourished [male/female] In no apparent distress</p><p><strong>Eyes:</strong> PERRL; anicteric sclera, conjunctiva moist</p><p><strong>HENT:</strong> Normocephalic, atraumatic, moist mucous membranes and OP benign, &nbsp;</p><p><strong>Neck:</strong> is supple, no thyromegaly, trachea midline</p><p><strong>Respiratory:</strong> &nbsp;No respiratory distress, normal breath sounds with good air movement throughout all lung fields; no rhonchi, wheezes, or crackles.</p><p><strong>Cardiovascular:</strong> S1 S2. &nbsp;Normal PMI. Capillary refill normal. No edema &nbsp;</p><p><strong>GI:</strong> &nbsp;Soft, non-tender, non-distended; normal active bowel sounds auscultated; no HSM or masses appreciated; no pulsatile masses. &nbsp;</p><p><strong>Musculoskeletal:</strong> &nbsp;Intact distal pulses, No clubbing, cyanosis; no tenderness to palpation or major deformities noted. &nbsp;Normal range of motion in neck</p><p><strong>Lymphatics:</strong> &nbsp;No cervical or supraclavicular lymphadenopathy</p><p><strong>Integument:</strong> &nbsp;Warm, dry, no erythema; No rash or petechia noted</p><p><strong>Neurologic:</strong> &nbsp;Alert &amp; oriented x 3, cranial nerves 2-12 grossly intact; no sensory or motor deficits appreciated; no focal deficits noted. &nbsp;</p><p><strong>Psych:</strong> Speech and affect appropriate</p><p><strong>LABS and Imaging &amp; Other Studies: </strong>All available laboratory and radiological data reviewed</p><p><strong>Medication:</strong></p><p><strong>Assessment and Plan:</strong></p><p><br data-cke-filler="true"></p><p><br data-cke-filler="true"></p><p>The Mississippi Prescription Monitoring Program is reviewed on regular intervals for patients receiving prescriptions through this clinic for controlled substances including narcotic pain medications.</p><p>Total time spent 60 minutes -minute visit include review and discussion with patient and/or patients family members regarding abnormal lab results, imaging studies, diagnostic possibilities, treatment options, risks and benefits. At least half of this time was spent in face to face counseling.</p><p>This note was created using voice recognition software. &nbsp;While efforts were made to review the note for speech recognition errors, occasionally errors are missed. Please contact me for corrections or to provide clarification if you feel that an error may be present.</p>