HISTORY
OBJECTIVE
General: alert - no distress - non-toxic
Eyes: no redness or drainage - lids normal
Ears: (R)TM appears normal - (L)TM appears normal
Nose: no drainage or congestion appreciated
Mouth: membranes moist - no oral lesions - tongue normal - soft palate normal
Pharynx: tonsils appear normal - posterior pharynx is normal
Neck: supple - no adenopathy
CV: RRR - extremities well perfused
Respirations: normal work of breathing - no retractions - RR normal - clear to auscultation
Abdomen: soft - NTND - no HSM/mass
Skin: warm and well perfused
ASSESSMENT & PLAN