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Fever Exam
Mar 31, 2010
•
Mark Morgan
categories:
Infectious Disease
Objective/Exam
Pediatrics
General: The patient is alert and in ***no/mild/moderate/severe*** distress. Abdomen: ***Is normal/Nontender/Bowel sounds are present/Normal liver/Normal spleen/Is abnormal*** ENT: Nose is ***normal/congested/not examined***. Mouth is ***moist/tacky/dry***. External examination of the ears: ***external examination of the ears/Normal/Abnormal/Not performed/Other***. Right tympanic membrane: ***Clear/Dull/Red/Fluid/Bulging/Distorted/Draining/Myringotomy tube present/Not performed***. Left tympanic membrane: ***Clear/Dull/Red/Fluid/Bulging/Distorted/Draining/Myringotomy tube present/Not performed***. Throat: ***Normal/Abnormal/Erythematous/Tonsils inflamed/Exudate present/Not performed***. Neck: ***Supple/Stiff/Kernig negative/Brudzinski negative/Not performed***. Eyes: ***Normal./Pupils equal, round, and reactive to light./Pupils are normal./Lids are normal./Conjunctivae are normal./No mattering.*** Genitalia: ***Normal male./Normal female./Abnormal.*** Head: Examination of the head ***is normal/reveals soft and flat fontanelles/reveals sunken fontanelles/reveals bulging fontanelles***. Heart: ***Normal/Normal heart sounds/Regular rate/Regular rhythm/No murmur/Abnormal*** Lungs: ***Clear to auscultation and percussion/Reveals scattered rhonchi/Reveals scattered wheezes/Reveals decreased breath sounds*** Lymph Nodes: Cervical adenopathy ***present on the left/present on the right/present bilaterally/not present***. Skin: ***Normal./Good turgor./Abnormal.***
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