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Today's Date
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Ped
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Referring MD
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OB-GYN Physician
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CNM
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Baby’s Age (days)
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GA (include weeks and days)
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Birth Hospital
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History of Illness/Symptoms
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History
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noted to have misshapen ears on
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by
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The delivery was complicated/uncomplicated
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Birth weight
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Pregnancy, L&D Complications
• • •
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Other pre/postnatal complications not listed
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multiple birth
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Siblings
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Past Medical History
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Passed hearing screen
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failed hearing
• • •
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repeat hearing screen date
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feeding
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IF NO PMH
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OTHER PMH
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Immunizations
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Family History
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no fam hx
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Positive family hx
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family member
• • •
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family ear hx
• • •
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Other family hx ear abnormality
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Past Surg Hx
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NO Past surg hx
• • •
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Positive PSH
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Allergies
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NO allergies
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Allergies to:
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Meds
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No Meds
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Medications
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ROS
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ROS negative
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Parents report of ROS
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Physical Exam
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Normal gen Exam
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Abnormal exam
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Ears
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Ear exam
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Left ear exam
• • •
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Right ear exam
• • •
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Same BILATERAL ears
• • •
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if deformity is SAME for both ears
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if deformity is SAME for both ears
• • •
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Unilateral Ear examination
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Left ear deformity
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Left ear dx
• • •
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Right ear deformity
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Right ear dx
• • •
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OTHER Description of ears
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Cartilage firmness
• • •
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Ear Measurements
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Ear Measurements
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Left Ear
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Lt Length
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Lt width
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Left helix
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Lt Mid-ear
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Lt lobule
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Right Ear
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Rt Length
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Rt width
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Rt helical apex
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Rt mid-ear
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Rt lobule
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Plan:
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EW Plan
• • •
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Reasons for no TX
• • •
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OTHER Plan
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Discussed risks, benefits
• • •
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Follow Up:
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follow up
• • •
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Patient Seen By MEM CITY
• • •
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Patient Seen By WOODLANDS
• • •
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Cradles Used
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New Patient Evaluation
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Cradle Lg Lt
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Cradle Lg Rt
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Cradle Md Lt
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Cradle Md Rt
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