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Poop
Poop
Objective Data
Vital Signs: Temp 37.5C, BP 108/60, HR 105, RR 24, O2 100% RA, Ht. 3’5” Wt. 40 lbs BMI:
16.7 85th percentile, pain 2/10 Wong-baker faces pain scale
Physical Exam
General (Constitutional): Shy but pleasant 5-year-old female, normal general appearance, sits
next mom, talkative
Skin: Warm and dry, no pallor or cyanosis
Lymph nodes: no lymphadenopathy noted
Head: NCAT, PERRL, red reflex present bilaterally, light reflex symmetrical, EOMI with no
strabismus
Ears: Left TM is red, bulging, and erythematous, fluid present behind membrane, loss of
landmark and light reflex. Mild pain on palpation. Right TM is pale and grey, landmark present
Eyes: PERRLA, no swelling or lesions over the orbital area, sclera white, conjunctiva moist and
pink
Nose: clear rhinorrhea present, septum midline
Neck: supple, shotty cervical adenopathy
Mouth/Throat: oral mucosa is moist, no lesions, throat without redness or swelling
Lungs: CTAB, no wheezes, rales, or rhonchi
Heart: RRR, no murmurs, rubs, or gallops
GI: Soft, NT/ND, NBS, no masses or organomegaly
MSK: No deformities, normal gait.
Neuro: AOx3, gross motor and sensation intact, normal muscle strength
Assessment
Diagnosis: Acute Otitis Media
Differential Diagnosis:
Plan