DOB:
11/21/16
Age:
5 year old
Date of service:
12/29/21
CHIEF COMPLAINT: Right Ear Pain
HISTORY OF PRESENT ILLNESS: Abigail presents with her mother. She has been fussy over the last 3 days a
Today she felt warm to touch and temperature at home was 99.8. No other signs or symptoms other than mom no
CURRENT MEDICATIONS: Tylenol as needed
DRUG ALLERGIES: NKDA RELEVANT
SOCIAL HISTORY: No Smoking in home. Lives with mom and dad and 2 older siblings
RELEVANT MEDICAL HISTORY: None
RELEVANT FAMILY HISTORY: None noted
REVIEW OF SYSTEMS CONSTITUTIONAL: Energy generally good, Weight stable, Eating and drinking fine
HEENT: No sore throat, No nosebleeds, No drainage or congestion except earlier in the week.
RESPIRATORY: No cough, No dyspnea, No wheezing
CARDIOVASCULAR: No chest pain
GI: No abdominal pain, No vomiting, No diarrhea
GU: No drainage or bleeding noted
SKIN: No rash
NEURO: No mental status changes
PHYSICAL EXAM WEIGHT: 42 pounds
VITALS: Temp: 101.2, Resp: 24, HR: 96
GENERAL: Awake, Alert
HEENT: Clear rhinorrhea, No erythema or exudate in throat, No conjunctival injection, left TM pearly gray, righ
RESPIRATORY: No distress heard
CARDIOVASCULAR: regular rate and rhythm
ABDOMEN: Soft and no tenderness noted
SKIN: pink, warm, dry, free of rash.
NEURO: Speech clear, Oriented MS: Good muscle strength
