Acute Pediatric Exams

Objective/Exam Elements, Pediatrics
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[select name="Q1" value="Febrile Infant|Fussy Infant|Chicken Pox|Croup|Upper Respiratory Infection"][conditional field="Q1" condition="(Q1).is('Febrile Infant')"][conditional field="Q1" condition="(Q1).is('Febrile Infant')"]
[textarea default="General Appearance: NAD, no lethargy, not toxic."]
[textarea default="Head: normal, fontanele is soft."]
[textarea default="Eyes: normal pupils, lids, and conjunctiva. No exudate."]
[textarea default="Nose: normal, without congestion."]
[textarea default="Ears: right ear clear. left ear clear."]
[textarea default="Throat: normal, without erythema or exudate."]
[textarea default="Cervical adenopathy: absent bilaterally."]
[textarea default="Neck: supple."]
[textarea default="Heart: RR, no murmur/click, S3/S4"]
[textarea default="Lungs: clear, no wheezes, retractions, or rhonchi."]
[textarea default="Abdomen: normal, nontender, bowel sounds are present, no hepatosplenomegaly"]
[textarea default="Extremities: normal. Capillary refill less than 2 seconds."]
[textarea default="Genitalia: normal."]
[textarea default="Skin: normal turgor, no rashes or lesions present."][/conditional][conditional field="Q1" condition="(Q1).is('Fussy Infant')"]
[textarea default="General Appearance: active. Not toxic, not irritable, not inconsolable, not lethargic or listless."]
[textarea default="Head: normal, fontanelle is soft."]
[textarea default="Eyes: normal pupils, lids, and conjunctiva."]
[textarea default="Ears: right ear clear. left ear clear."]
[textarea default="Throat: normal, without erythema or exudate."]
[textarea default="Neck: normal, Kernig and Brudzinski negative."]
[textarea default="Heart: normal heart sounds, no murmur."]
[textarea default="Lungs: clear, without rhonic."]
[textarea default="Abdomen: no tenderness, no mass nor organomegaly, normal bowel sounds."]
[textarea default="Extremities: normal. Capillary refill less than 2 seconds."]
[textarea default="Skin: normal turgor, no rashes or lesions present."][/conditional][conditional field="Q1" condition="(Q1).is('Upper Respiratory Infection')"]
[textarea default="General Appearance: NAD, Alert, well nourished and well hydrated, non-toxic appearing in no medical distress."]
[textarea default="HEENT: Conjunctiva normal, Auditory canals and TM's normal, nares clear rhinorrhea bilaterally, oral exam without lesions, palate, tonsillar pillars and posterior pharynx non-erythematous. No palpable sinus pain."]
[textarea default="Neck: supple, no adenopathy."]
[textarea default="Lungs: clear to auscultation without wheezes, rales, or rhonchi. Good excursions."]
[textarea default="Heart: RRR with normal S1, S2 without murmur, gallop, or rub."]
[textarea default="Abdomen: soft, flat; no masses, tenderness or organomegaly."]
[textarea default="Skin: No rash present."]
[textarea default="Extremities: normal. Capillary refill less than 2 seconds."][/conditional][conditional field="Q1" condition="(Q1).is('Croup')"]
[textarea default="General Appearance: no acute respiratory distress. Non-toxic appearing. Without barky cough or hoarse voice."]
[textarea default="Ears: bilaterally intact TMs without bulging or erythema."]
[textarea default="Throat: normal, without exudate or tonsillar hypertrophy."]
[textarea default="Lymph nodes: normal, without anterior or posterior cervical adenopathy."]
[textarea default="Heart: RR, no murmur/click, S3/S4."]
[textarea default="Lungs: clear. No nasal flaring. No intercostal retractions. No stridor. No wheezes, rhonchi, or crackles."]
[textarea default="Abdomen: normal bowel sounds, soft, nontender."]
[textarea default="Extremities: Capillary refill is normal, less than 2 seconds."]
[textarea default="Skin: Color is good, without cyanosis."][/conditional][conditional field="Q1" condition="(Q1).is('Chicken Pox')"]
[textarea default="The patient is alert, NAD. Non-toxic appearing."]
[textarea default="Eyes: PERRL, conjunctiva normal. lids are normal."]
[textarea default="Ears: canals and tympanic membranes intact and without erythema bilaterally."]
[textarea default="Oropharnynx: no ulcers or vesicles. no erythema or exudate at posterior pharynx."]
[textarea default="Lungs: clear without rhonchi or wheezes."]
[textarea default="Heart: RR, normal heart sounds, no murmur."]
[textarea default="Skin: no vesicular eruption typical of varicella, no areas of impetiginization."]
[textarea default="Extremities: capillary refill less than 2 seconds."][/conditional]
[html]<hr>[/html][checkbox memo="display/hide references & code" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][html]
reference: none
posted by: Mark Morgan, M.D.
post/review dates: November 26, 2010; September 7, 2015
revision history: <a href="https://github.com/soapnote/SOAPnote-site/tree/master/generator/txt/child-health/acute-exams.txt" target="_blank">www.github.com/soapnote/SOAPnote-site/tree/master/generator/txt/child-health/acute-exams.txt</a>
markup link: <a href="../../generator/txt/child-health/acute-exams.txt" target="_blank">www.soapnote.org/generator/txt/child-health/acute-exams.txt</a>[/html][/conditional]


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