HPI: ID: Age at birth - TTN, < 3 months - septic work up, < 2year- bronchiolitis , 6 mos -> 3 years croup, asthmatic O: sudden, post viral D:acute or chronic > 8 weeks F: Dry/ Productive - pneumonia Painful/painless Time of day: asthma Worse exertion Post nasal drip: worse in the am, chronic tickle Bronchiolitis: sick, febrile dyspnea in infant < 2 years old, coryzal prodrome lasting 1 to 3 days, persistent cough and wob and wheeze/ crackles. Peaks 3-5 days Pertinent Negatives by Diagnosis Viral Pharyngitis/ common cold Strep throat/ bacterial phryngitis: pain, centor score Asthma: no history of atopy, not worse at night in the cold, with exercise, no wheeze, dyspnea, no puffer Pneumonia: no fever, purulent sputum, SOB, chest pain or pleurisy, Sinusitis: No frontal headache, maxillary or frontal sinus pressure, coryza, dental pain, fever GERD : no heartburn or reflux, unrelated to meals, Foreign body: no unobserved sudden onset PE: No hemoptysis, leg pain, or history of immobilization Cancer: no weight loss, night sweats, Croup ( viral tracheitis): not peak age 0.5 - 3 years, no coarseness or stridor, Bacterial Tracheitis:.5- 14 years, like croup but high fever no response to epi Epiglottitis: drooling, can't swallow saliva RED Flags Drooling Choking, SOB Hemoptysis Exposure to chemical, TB, HIV Weight loss Physical exam VITALS: HEENT: RESP: SKIN:
There are 0 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 213 boilerplate words
More SOAPnotes by this Author:
Send Feedback for this SOAPnote
You must be logged in to post a comment.