Allergy & Otolaryngology
Loading Add to Favorites
Share
Tweet
Cite
[comment memo="HPI"]
Patient presents for evaluation of [select name="variable_2" value="|gradual onset|acute onset"] [text name= default=""][comment memo="duration"][text name= default=""] days.
[text name="variable_15" default=""]

Patient reports associated symptoms of [checkbox name= value="sore throat|cough|nasal congestion|rhinorrhea|fever|fatigue|headache|abdominal pain|diarrhea|ear pain| facial pain| ansomia |Dysgeusia |Appetite decreased| normal wet nappies| decreased wet nappies"]


Patient denies[checkbox name= value="dysphagia|neck swelling|cough|nasal congestion|rhinorrhea|fever|fatigue|headache|abdominal pain|diarrhea|ear pain| facial pain|CP|SOB|LE edema|syncopy|Hemoptasis"]

Patient reports [select name= value="no sick contacts|sick contacts"].

Treatment [checkbox value="None|acteminophen|ibuprofen|Tylenol|OTC cough medications|DayQuil"] for symptoms. [select name="variable_1" value="with symptoms relief|without symptoms relief|with partial symptoms relief"]


[text name="variable_1" default=""]


MDM:
[checkbox name="variable_5" value=" Vital signs revealed no major abnormalities|no fever|no tachycardia|no tachypnea|no hypotension| non toxic appearing|fever|hypoxia|tachycardia|hypotension|ill appearing"]

DDx considered:
[checkbox name="variable_6" value=" Strep throat|Tonsilitis|viral pharyngitis|otitis media|hand-foot-and-mouth syndrome|mononucleosis|Sinus infection|peritonsillar/retropharyngeal abscess |gonorrhea, chlamydia|thyroiditis|jugular vein thrombosis"] These were thought to be less likely given the history, exam, and workup.


Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Patient advised to follow up with primary care in three to five days, Call the clinic or urgent care with new or worsening symptoms.
Return and follow up instructions provided, patient verbalized understanding.
present to ER with new or worsening symptoms which discussed during the visit.
HPI
Patient presents for evaluation of duration days.


Patient reports associated symptoms of


Patient denies

Patient reports .

Treatment for symptoms.





MDM:


DDx considered:
These were thought to be less likely given the history, exam, and workup.


Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Patient advised to follow up with primary care in three to five days, Call the clinic or urgent care with new or worsening symptoms.
Return and follow up instructions provided, patient verbalized understanding.
present to ER with new or worsening symptoms which discussed during the visit.

Result - Copy and paste this output: