Acute Pediatric Exams
[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]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.02, 57 form elements, 50 text areas, 1 drop downs, 6 conditionals, 51 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote