|
HPI
|
|
|
Location
• • •
|
Associated symptoms
• • •
|
|
Onset
• • •
|
|
|
No medications PTA
|
Moderate. Sudden onset. Constant.
|
|
No prior episodes of similar symptoms.
|
Improved with Benadryl.
|
|
Triggers:
|
Similar to prior allergic reactions.
|
|
No oral mucosal membrane ulceration
|
No difficulty swallowing.
|
|
No difficulty breathing.
|
No intraoral swelling.
|
|
No fevers.
|
No paresthesias at rash.
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Skin: _______
|
|
|
ENT (positive findings)
• • •
|
ENT (negative findings)
• • •
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Additional (Insert Macro)
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Location: *
• • •
|
|
|
Skin (positive)
• • •
|
Skin (negative)
• • •
|
|
Additional:
|
|
|
Superficial
|
Head to toe exam
|
|
PE Macro
|
|
|
|
|
|
MDM
|
|
|
Differential Diagnosis: Allergic reaction, cellulitis, asthma, Stevens-Johnson, TEN
|
MDM
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Plan Notes:
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
Clinician Attestation
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
