|
The presents today for evaluation of:
|
Onset:
• • •
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Duration
|
|
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HPI
|
|
|
Pertinent positives
• • •
|
Pertinent Positives
|
|
Pertinent negatives
• • •
|
Negative for
|
|
Severity*
|
|
|
Moderate. No SOB or difficulty swallowing.
|
Course*
• • •
|
|
Sick contacts:
|
Fever
|
|
OTC meds
• • •
|
|
|
Palliating factors include
|
Provoking factors include
|
|
Additional notes
|
|
|
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
ENT (positive)
• • •
|
ENT (negative)
• • •
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
General:
|
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Skin
|
|
|
Skin (abnormal):
|
|
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Head
|
|
|
Eyes
|
Eyes (abnormal)
|
|
Ears:
|
Ears (abnormal)
|
|
Sinuses
|
|
|
Nose
|
Nose
|
|
Mouth
|
Mouth
|
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Throat
|
Mouth
|
|
Neck
|
Neck
|
|
Heart:
|
Heart
|
|
Lungs
|
Lungs abnormal
|
|
ENT: pharynx: erythematous, otherwise neg
|
|
|
ENT (positive)
• • •
|
ENT (negative)
• • •
|
|
Lungs: CTAB. No wheezing, rales or rhonchi
|
|
|
Insert PE Macro Here
|
|
|
Centor score
|
Age
|
|
Exudate or swelling on tonsils
|
Tender/swollen anterior cervical lymph nodes
|
|
Temp > 38°C (100.4°F)
|
Cough
|
|
Score:
|
|
|
Diagnosis:
• • •
|
Diagnosis:
|
|
PLAN
|
|
|
POC Medications Given
• • •
|
Plan Notes
|
|
Discharge pt home
|
Discharge: Notes
|
