Procedure Note
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HISTORY:
[checkbox name="historian" value="provided by patient||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=1]

CC:
[checkbox name="cc" value="earache|pressure|discharge|hearing loss|possible foreign body|trauma|bleeding|ringing|"][textarea cols=70 rows=1]

AFFECTED EAR:
[checkbox name="which_ear" value="right|left|both|"][textarea cols=70 rows=1]

HPI:
[checkbox name="hpi" value="sudden onset|gradual onset||started just prior to arrival|started today|started yesterday|started days ago|started months ago||sx increasing in severity|sx persisting|sx decreasing in severity|sx fluctuate||no similar sx previously|similar sx previously|"][textarea cols=70 rows=1]

MEDICATIONS:
[checkbox name="medications" value="allergies reviewed|taking OTC, not helping|taking ABX, not helping|not taking any medications|"][textarea cols=70 rows=1]

PMSH:
[checklist name="pmh" value="sick contact|recent PCP visit|recent ER/UC visit|recent travel|frequent OM|recent ABX use|tubes|hearing aid"]

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL: [textarea cols=70 rows=1]
[checklist name="const_symptoms" value="objective fever|subjective fever|chills|fatigue"]
EYES: [textarea cols=70 rows=1]
[checklist name="eye_symptoms" value="vision loss|photophobia|redness|discharge|lid swelling|periorbital swelling|pain with EOM"]
NOSE: [textarea cols=70 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|bleeding"]
MOUTH: [textarea cols=70 rows=1]
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache"]
THROAT: [textarea cols=70 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness"]
NECK: [textarea cols=70 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=70 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=70 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing|cough|wheezing"]
GI: [textarea cols=70 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|heartburn|gas|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=70 rows=1]
[checklist name="gu_symptoms" value="dysuria|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|incontinence|inguinal swelling|genital itching/lesions|discharge"]
MSK: [textarea cols=70 rows=1]
[checklist name="msk_symptoms" value="neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds|localized joint pain/deformity|generalized joint pain|localized muscle/soft tissue pain/swelling|myalgias"]
NEURO: [textarea cols=70 rows=1]
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=70 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA: [textarea cols=70 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=70 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]
DERM: [textarea cols=70 rows=1]
[checklist name="derm_symptoms" value="dryness|pruritus|rash/redness|swelling|wounds|new or suspicious lesions"]



Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB||allows exam|poor cooperation with exam|crying but consolable||ill-appearing|tired-looking|short of breath|diaphoretic||drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="warm, dry|grossly intact, no rashes|no bruises|normal turgor|dry||tattoos|body piercings||pallor|cyanosis|poor turgor|diaphoresis|rash|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|contacts||conjunctival injection|epiphora|conjunctival exudate||allergic shiners|dennie lines||periorbital swelling|palpebral edema|palpebral exudates||ptosis|chemosis|hyphema|dysconjugate gaze|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||mucosal swelling/erythema|clear discharge|purulent discharge||facial tenderness|deviated septum|active septal hemorrhage|dried up blood|"][textarea cols=70 rows=1]

Mouth/Throat:
[checkbox name="throat" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions|normal voice|patent pharynx w/o swelling or exudates||hoarseness|tooth decay||pharyngeal erythema w/o exudates|pharyngeal crowding|tonsillar enlargement|tonsillar erythema|tonsillar exudates|tonsillar crypts|tonsilar pustules|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no LAD|no bruit or JVD||anterior LAD|posterior LAD||nuchal tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|no retractions|clear and equal breath sounds bilaterally||cough|breath sounds decreased bilaterally|wheezing|crackles||poor effort|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="not examined|normal visual inspection, no distension||normal active bowel sounds|soft non-tender||protruding|surgical scar|umbilical hernia||diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined||no suprapubic tenderness|no CVAT bilaterally|normal external genitalia|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for age||C-spine tenderness & DROM|neck pain with active motion|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="ambulates w/o limp or alteration in gait|balance & coordination grossly intact|extremities strong w/o atrophy, tremor or fasciculations||normal speech|normal concentration and attention|memory grossly intact||no gross motor deficits|sensation symmetrical & grossly intact||antalgic gait|wide gait|shuffling gait|dystonia|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam|poor cooperation with exam||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||demanding particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical||circumstantial|tangential|perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting||delusions|paranoid ideation|"][textarea cols=70 rows=1]

Right Ear:
[checkbox name="right_ear" value="auricle intact|no mastoid tenderness|no canal swelling|no material present in canal|no FB visible in canal|normal TM||pain w movement of auricle|tragal tenderness|canal swelling|pustule in canal|cerumen in canal|dried up blood in canal|FB in canal||TM erythema|TM dullness/loss of landmarks|TM bulging|TM perforation|tube intact in TM|fluid behind TM|TM obscured by wax||mastoid tenderness|"][textarea cols=70 rows=1]

Left Ear:
[checkbox name="left_ear" value="auricle intact|no mastoid tenderness|no canal swelling|no material present in canal|no FB visible in canal|normal TM||pain w movement of auricle|tragal tenderness|canal swelling|pustule in canal|cerumen in canal|dried up blood in canal|FB in canal||TM erythema|TM dullness/loss of landmarks|TM bulging|TM perforation|tube intact in TM|fluid behind TM|TM obscured by wax||mastoid tenderness|"][textarea cols=70 rows=1]
OFFICE DIAGNOSTICS:
[checkbox name="office" value="none|reviewed:"][textarea cols=70 rows=1]


[comment memo="DX:
acute otalgia
hearing loss
otitis externa
impacted cerumen
otitis media
otitis media w effusion
foreign body to ear
perforated TM
URI
TMJ syndrome"]


PLAN OF CARE:
[checkbox name="poc" value="POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||did not agree with my POC/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

PROCEDURE:
[checkbox name="procedure" value="N/A|attempt to remove cerumen using curette was unsuccessful|attempt to remove FB w forceps was unsuccessful|liquid medication instilled|ear lavage completed by MA||reexamined by provider|canal clear, TM intact|no FB present|no active bleeding|tolerated procedure well|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

LABS/IMAGING:
[checkbox name="order_lab" value="none|throat cx|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|previous visits|PMP/CURES|previous laboratory/diagnostic studies|specialty reports|hospital discharge|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|laboratory/diagnostic studies|appropriate follow up|reporting medication side effects immediately||controlling chronic conditions|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|incomplete history|vague shifting complaints|history not supported by objective findings||poor compliance with POC|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds||frequent ER/UC visits|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||RTC 24 hours|RTC 48 to 72 hours|RTC 1 week||refer to ENT||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]
HISTORY:


CC:


AFFECTED EAR:


HPI:


MEDICATIONS:


PMSH:


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

EYES:

NOSE:

MOUTH:

THROAT:

NECK:

CV:

CHEST/RESPIRATORY:

GI:

GU:

MSK:

NEURO:

PSYCH:

LYMPH/HEMA:

ALLERGIES/IMMUNE:

DERM:




Appearance:


Skin:


Head/Face:


Eyes:


Nose:


Mouth/Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


Right Ear:


Left Ear:

OFFICE DIAGNOSTICS:



DX:
acute otalgia
hearing loss
otitis externa
impacted cerumen
otitis media
otitis media w effusion
foreign body to ear
perforated TM
URI
TMJ syndrome



PLAN OF CARE:


PROCEDURE:


RX:


LABS/IMAGING:


REVIEWED:


INSTRUCTED ON:


BARRIERS TO CARE:


DISPOSITION:

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