Otitis Media Exam
[textarea columns=80 rows=25 default="VITALS: Reviewed and normal/*** GENERAL: Alert, well nourished and well hydrated, in no distress. HEENT: Conjunctiva normal - Ears: Auditory canals normal/TM normal on R side/TM normal on L side/R TM bulging and erythematous/L TM bulging and erythematous/both TM's bulging and erythematous/immobile on insufflation/perforation present with purulent debris in external canal/perforation present without purulent debris in external canal - Nares clear rhinorrhea bilaterally - Oral exam without lesions/posterior pharynx non-erythematous/Tonsils with hypertrophy/exudate/erythema NECK: Supple/Shotty adenopathy anteriorly/Anterior cervical adenopathy/Posterior cervical adenopathy LUNGS: Clear to auscultation without wheezes, rales, or rhonchi. Good excursions. No dullness on percussion. HEART: RRR with normal S1, S2 without murmur, gallop, or rub. ABD: Soft, non-tender, without hepatosplenomegaly SKIN: No rash present"]
There are 1 form elements.
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0, 1 form elements, 1 text areas, 1 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote
You must be logged in to post a comment.