5 – Ear

[checkbox name="historian" value="history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]
CC: [checkbox name="cc" value="earache|pressure|discharge|hearing loss|possible foreign body|trauma|bleeding|ringing|"][textarea cols=50 rows=3]
AFFECTED EAR: [checkbox name="which_ear" value="right|left|both|"][textarea cols=70 rows=1]
HPI/SYMPTOMS: [checkbox name="hpi" value="started today|started yesterday|started several days ago|started more than 1 week ago|started months ago|started years ago||still present|increasing in severity|persisting|occasional|decreasing|resolved||as in cc|"][textarea cols=50 rows=3]

MEDICATIONS: allergies reviewed, [checkbox name="medications" value="taking OTC|taking RX||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages|unable to name medications/reasons/dosages||none reported|"][textarea cols=50 rows=3]

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|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"]



OFFICE DIAGNOSTICS: [checkbox name="office" value="none||rapid strep NEG|rapid strep POS||rapid flu NEG|rapid flu POS||rapid C19 antigen NEG|rapid C19 antigen POS||rapid C19 antibody NEG|rapid c19 antibody POS||CXR|"][textarea cols=50 rows=3]
Appearance: [checkbox name="appearance" value="well-appearing|alert, non-toxic, normal WOB||crying but consolable|speaking in full sentences||ill-appearing|tired-looking|short of breath|diaphoretic||drowsy|appears impaired|slumped||heavy built|muscular|lean|well-nourished|frail|"][textarea cols=50 rows=3]
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=50 rows=3]
Head/Face: [checkbox name="head" value="normocephalic, atraumatic, symmetrical face|CN grossly intact|"][textarea cols=50 rows=3]
Eyes: [checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus, visual acuity grossly intact||conjunctival injection|epiphora|conjunctival exudate||allergic shiners|dennie lines||palpebral edema|palpebral exudates||glasses|contacts|"][textarea cols=50 rows=3]
Nose: [checkbox name="nose" value="nares patent bilaterally, septum midline|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness||deviated septum||mucosal edema|clear discharge|purulent drainage|"][textarea cols=50 rows=3]
Mouth: [checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements, moist oral mucosa without lesions||upper denture|lower denture|poor dentition|tooth decay||single oral ulcer|multiple oral ulcers|gum swelling|"][textarea cols=50 rows=3]
Throat: [checkbox name="throat" value="normal voice, no stridor, patent pharynx w/o swelling or exudates|uvula midline||hoarseness|inspiratory stridor|muffled voice||vesicles on soft palate|petechiae on soft palate||pharyngeal erythema w/o exudates|pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules|"][textarea cols=50 rows=3]
Neck: [checkbox name="neck" value="symmetric with free painless ROM, no masses noted|no LAD||anterior LAD|posterior LAD|"][textarea cols=50 rows=3]
Chest: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, chest wall atraumatic and non-tender|no retractions||clear and equal breath sounds bilaterally|no axillary or supraclavicular LAD||respiratory distress|breath sounds decreased bilaterally|coughing|poor effort||expiratory wheezing|crackles||regular rhythm|no murmurs|no ankle edema||tachycardia|irregular heart rhythm|systolic murmur||ankle edema|varicosities|stasis discoloration|calf tenderness|"][textarea cols=50 rows=3]
Abdomen: [checkbox name="abd" value="normal visual inspection|no distension|protruding||normal bowel sounds|soft|non-tender||guarding|diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness||hypoactive bowel sounds|hyperactive bowel sounds||not examined|"][textarea cols=50 rows=3]
GU: [checkbox name="gu" value="no suprapubic tenderness|no CVAT bilaterally||normal external genitalia||not examined|"][textarea cols=50 rows=3]
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 patient’s age|"][textarea cols=50 rows=3]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical & grossly intact||no involuntary movements or tremor||tardive dyskinesia|tics|"][textarea cols=50 rows=3]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive/argumentative|cursing/swearing||previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=1]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful, cooperative with history & exam||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 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=50 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=50 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"]

Discussion:
[textarea cols=50 rows=5]

.
PLAN OF CARE: patient/family verbalized understanding of dx & POC, [checkbox name="discussed" value="agreed with dx & POC|did not agree with dx & POC – encouraged to seek second opinion|"][textarea cols=50 rows=3]
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=50 rows=1]
ORDERS - MA: [checkbox name="order_MA" value="injection|Rocephin 1 gm IM now|Dexa 8 mg IM now||none|"][textarea cols=50 rows=1]
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"]
[textarea cols=50 rows=1]
[textarea cols=50 rows=1]
[textarea cols=50 rows=1]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|UA||c19 PCR||none|"][textarea cols=50 rows=2]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US|MRI||none|"][textarea cols=50 rows=3]
ORDERS - FORMS: [checkbox name="forms" value="POC test results|excuse|accomodations|clearance|return to school/work|school/participation physical||none|"][textarea cols=50 rows=3]
REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct (re)evaluation and/or contacting emergency services, [checkbox name="instructions" value="medications|previous visits|laboratory/diagnostic studies||expect call from clinic for any abnormal diagnostic studies|contact clinic for diagnostic results if not received call||specialty reports|hospital discharge||medication compliance|bringing all medications/labels to all visits||home BP checks|home BS checks|daily weights||controlling chronic conditions|age-appropriate screening and immunization|annual eye exam|"][textarea cols=50 rows=1]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged|appears well|non-toxic|physical exam unremarkable for any emergent condition||no safety concerns at this time|safety concerns d/t depressed agitated mood|safety concerns d/t impulsiveness|safety concerns d/t hostile temper|safety concerns d/t past attempts|safety concerns d/t current suicidal verbalization|"][textarea cols=50 rows=1]
DISPOSITION: [checkbox name="disposition" value="home|quarantine 10-14 days||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left exam room before visit conclusion|asked to leave clinic|"][textarea cols=50 rows=1]
FOLLOW UP: 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, [checkbox name="next" value="here|in-person|televisit|w PCP||24 hours|2-3 days|1 week||f/u acute episode|f/u labs|f/u imaging|f/u med change/new|"][textarea cols=50 rows=2]
BARRIERS TO CARE: [checkbox name="barriers" value="incomplete history|poor cooperation with exam|language barrier|affect|socio-cultural factors||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable|poor compliance with POC||intolerance of/therapeutic failure on multiple meds|negative attitude to diagnostic impression & proposed tx|lack of interest in nonpharmacologic therapies||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others||hostile/disruptive behavior||none noted at this time|"][textarea cols=50 rows=1]