|
HPI
|
|
|
Onset
• • •
|
Course
• • •
|
|
Severity
|
+ sore throat
|
|
No SOB
|
Dry cough
|
|
No sick contacts
|
No difficulty swallowing
|
|
fever
|
Close contacts with similar symptoms.
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
CV (positive)
• • •
|
CV (negative)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Insert ROS Macro Here
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
Lungs: CTAB.
|
|
|
Respiratory (positive)
• • •
|
Respiratory (negative)
• • •
|
|
Respiratory additional:
|
|
|
CV (positive)
• • •
|
CV (negative)
• • •
|
|
ENT: No pharyngeal erythema or exudates.
|
|
|
PE: Superficial
|
PE: Head to toe exam
|
|
PE Macro
|
|
|
|
|
|
MDM
|
|
|
DDx: PNA, Bronchitis, viral syndrome, PE, CHF, PTX
|
MDM Notes
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis
|
|
Status
|
Diagnosis
|
|
Status
|
Diagnosis
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
|
|
Plan notes:
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
|
|
|
Clinician Attestation
|
|
