|
HPI
|
|
|
Severity
|
Location
• • •
|
|
Onset:
• • •
|
Course
• • •
|
|
No FB
|
Fever?
|
|
Hearing loss?
|
|
|
Description of foreign body:
|
|
|
Additional notes
|
|
|
|
|
|
REVIEW OF SYSTEMS
|
|
|
Positive (ENT)
• • •
|
Negative (ENT)
• • •
|
|
Constitutional (positive)
• • •
|
Constitutional (negative)
• • •
|
|
Additional
|
All systems otherwise negative.
|
|
|
|
|
PHYSICAL EXAM
|
|
|
ENT: Negative external and internal ear exam
|
|
|
Positive findings (ENT)
• • •
|
Negative (ENT)
• • •
|
|
Mastoid tenderness?
|
Additional ENT
|
|
PE: Superficial
|
PE: Head to toe exam (abd deferred)
|
|
Insert Macro Here
|
|
|
|
|
|
MDM
|
|
|
DDx: otitis media, otitis externa, otalgia, mastoiditis
|
MDM
|
|
Status
|
Diagnosis:
• • •
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
Status
|
Diagnosis:
|
|
|
|
|
DISCHARGE
|
|
|
POC Medications Given
• • •
|
Pt referred to ENT for further eval and testing.
|
|
Plan Notes
|
|
|
Discharge pt home
|
Discharge pt to ER
|
|
|
Mode of Transport to ER
|
|
|
ER Transfer Comments
|
|
|
|
|
Clinician Attestation
|
|
