Sav’s Basic Note

[textarea name="variable_1" fillable="true"]HISTORY OF PRESENT ILLNESS:

**Patientname** is a **patientage** old **female/male** who presents for evaluation of ***. Symptoms have been present for *** days. Patient reports ***headache/fever/nausea/rash/cough/myalgias/malaise/swollen lymph nodes/no headache/no fever/no nausea/no cough***.

REVIEW OF SYSTEMS:
All systems reviewed and negative except as noted per HPI.[/textarea]
[textarea name="variable_3" fillable="true"]PHYSICAL EXAMINATION:

General: Well appearing, well nourished, well developed and age appropriate. Well groomed, interactive in no acute physical or emotional distress. Vitals reviewed and stable.

Skin: Appropriate for ethnicity, warm, dry, normal turgor and without rashes.

Head: Normocephalic, atraumatic.

Eyes: Sclerae clear, no visible drainage, eyelid edema or erythema. PERRLA bilaterally. 

Ears: Tympanic membranes pearly-grey with good light reflex and visible landmarks bilaterally. ***Right tympanic membrane is erythematous, bulging with air fluid levels behind it, external canal is erythematous, swollen, cerumen impaction, and foreign body in ear canal.*** Left tympanic membrane is erythematous, bulging with air fluid levels behind it, external canal is erythematous, swollen, cerumen impaction, and foreign body in ear canal***.

Nose: Nose clear, inferior turbinates normal bilaterally, septum midline and intact.***Nares patent but pale bilaterally, boggy anterior turbinates/epistaxis/rhinorrhea/purulent discharge/sinus tenderness/deviated nasal septum***

Oral cavity and pharynx: Mucous membranes moist. Palate clear and intact. Dentition normal for age. Uvula midline, no oral lesions, posterior oropharynx clear. Tonsils non-erythematous or edematous without exudate, vesicles, or ulcerations bilaterally.***Posterior oropharynx is erythematous without exudate or lesions/posterior oropharynx is erythematous with white exudate/posterior oropharynx has clear drainage and cobblestoning/tonsillar pillars are 1+/tonsillar pillars are 2+/tonsillar pillars are 3+/tonsillar pillars are covered with exudate/tonsils***

Lymph: No significant lymphadenopathy appreciated. ***Anterior cervical lymphadenopathy/posterior cervical lymphadenopathy/submandibular lymphadenopathy/no lymphadenopathy/neck tenderness/diffuse enlargement of the thyroid/neck is supple/neck is rigid/TMJ tenderness***

Cardiovascular: Regular rate and rhythm. Normal S1 and S2. No murmurs, gallops, or rubs. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused, without clubbing, cyanosis or edema. Distal capillary refill is less than 2 seconds.

Lungs: Unlabored respirations. Normal rate. Symmetric chest expansion. Breath sounds clear to auscultation bilaterally. No wheezes, crackles, rales, rhonchi, or retractions. *** Diminished breath sounds --- lobe/rales in the --- lobe/rhonchi in the --- lobe/inspiratory wheezing --- lobe/expiratory wheezing --- lobe/dullness to percussion lobe/good air movement/fair air movement/poor air movement/labored breathing***

MSK: Normal active and passive ROM.

Neuro: Alert, no focal deficits observed.
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[textarea name="variable_4" fillable="true"]ASSESSMENT/PLAN:

Medical Decision Making
**Patientname** is a **patientage** old **female/male** who presented for ***. 

Differential Diagnoses:I considered: ****

Physical exam and history is consistent with ***.

Treatment Plan
I have recommended the following for the treatment plan:***
Encouraged supportive care, observation and encouraging fluid intake.
Provided recommendations and education regarding ***
We discussed return precautions versus when to have child seen in ED for further work-up and evaluation as well as when to call 911.

***Patient and parent verbalized understanding of this plan and when to seek further evaluation.

Assessment: Final Diagnosis:
-*** + ICD10 code

Disposition:
-Condition of patient: Stable. [/textarea]