Complete Note
Loading Add to Favorites
Share
Tweet
Cite
[checkbox name="variable_1" value="Patient presents with |Brought in by parent for the evaluation of |Brought in by parents who are concerned because the child has been having "][checkbox value="fever|chills|runny nose|ear pain|productive cough|dry cough|sore throat|pain with swallowing|hoarseness|watery eyes|body aches|itchy eyes|sinus pain in cheeks and/or forehead"] [checkbox name="variable_2" value="for the past 1 day.|for the past 2 days.|for the past 3 days."] [text name="variable_3" default=""].
The fever has been as high as [text name="variable_4" default=""] [checkbox name="variable_5" value="38C|38.5C|39C|39.5C |40C "] and has been treated with [text name="variable_7" default=" ml"][checkbox name="variable_6" value="Ibuprofen,|Paracetamol"][text name="variable_27" default=" ml"] , [checkbox name="variable_8" value="with good results.| without result."]
Appetite is [checkbox name="variable_18" value="normal.|decreased.|lower than normal."]
Pt is [checkbox name="variable_9" value="active.|tired.|irritated."]
No [checkbox name= value="sore throat| cough|nasal congestion|rhinorrhea| fever|fatigue|headache|abdominal pain|diarrhea|ear pain| facial pain|SOB |dyspnea|headache"].
The patient has [checkbox name="variable_10" value="been exposed to ill contacts.|not been exposed to ill contacts."] [checkbox name="variable_11" value="Attends day care."]
[checkbox memo="Me shume" name="B" value=""][conditional field="B" condition="(B).is('')"][textarea]Allergies
Medications
FH
MH/SH
SocHx[/textarea][/conditional]

Subjective
General: The patient is alert and in [checkbox name="variable_12" value="no distress|mild distress|moderate distress"] [text name="variable_25" default=""].
Skin: [checkbox name="variable_14" value="Good turgor|no rash|no unusual bruising"][text name="variable_26" default=""].
Eyes: [checkbox name="variable_13" value="Conjunctiva clear|sclera non-icteric|PERRL"] [text name="variable_13" default=""].
Ears: [checkbox name="variable_15" value="No tenderness|EACs clear|TMs translucent & mobile, ossicles nl appearance|hearing intact"] [text name="variable_16" default=""]
Nose [checkbox name="variable_17" value=" No external lesions| no nasal discharge| Mucosa non-inflamed| septum and turbinates normal"][text name="variable_17" default=""].
Mouth: [checkbox name="variable_19" value="Mucous membranes moist| no mucosal lesions"][text name="variable_19" default=""].
Pharynx: [checkbox name="variable_20" value="Mucosa non-inflamed| no tonsillar hypertrophy or exudate"] [text name="variable_20" default=""].
Neck: [checkbox name="variable_21" value="Supple.| Without adenopathy.| Thyroid non-enlarged and non-tender"] [text name="variable_21" default=""].
Heart: [checkbox name="variable_22" value="S1+S2+0| Regular Rate and Rhythm.| no murmur or gallop"] [text name="variable_22" default=""].
Lungs: [checkbox name="variable_23" value="Clear to auscultation| Normal vesicular breath sounds bilaterally.| No wheezes,rales or rubs"] [text name="variable_23" default=""].
Abdomen: [checkbox name="variable_24" value="Bowel sounds normal| no tenderness| no organomegaly"] [text name="variable_24" default=""].

Assessment
[checkbox name="variable_28" value="Fever|Fever unspecified|Viral URI"]

Plan
[checkbox name="variable_30" value="Explained findings to the parent|Explained findings to the pt"]
Use[text name="variable_32" default=" ml"] [checkbox name="variable_31" value="of Ibuprofen 100mg/5ml|Ibuprofen|every 8 hours"] and [text name="variable_34" default=" ml"] [checkbox name="variable_33" value="Paracetamol 120mg/5ml|Paracetamol| every 6 hours| use both interchangeably every 4 hours"].
Advised [checkbox name="variable_38" value="to come back if fever lasts more than 5 days total|parents to bring child back if symptoms change or parents are worried|recheck if not improved in one week or sooner if worsening. "]. [checkbox name="variable_35" value="Pt|Parents"] verbalized understanding and agreement.
.
The fever has been as high as and has been treated with ,
Appetite is
Pt is
No .
The patient has
Me shume

Subjective
General: The patient is alert and in .
Skin: .
Eyes: .
Ears:
Nose .
Mouth: .
Pharynx: .
Neck: .
Heart: .
Lungs: .
Abdomen: .

Assessment


Plan

Use and .
Advised . verbalized understanding and agreement.
Result - Copy and paste this output: