Toby, et al
Here you go:
This is what comes up when I say "exam bronchitis"
WNWD in NAD
HEENT: TMs normal
oropharynx without erythema or exudate
neck supple
LYMPH: anterior cervical nodes not enlarged
CHEST: normal excursion
LUNGS: rhonchi present, no rales or wheezes
HEART: RRR without m/r/g
And, this is what comes up when I say "plan bronchitis" :
Symptomatic relief with OTC medications.
Plenty of fluids.
Recheck if there are worsening symptoms, such as a higher fever, shortness of breath, or chest pain.
I leave a blank line at the top of the plan, so I can insert an antibiotic rx if I want to - I simply dictate it in. Here's what it looks like with an rx of Zithromax:
Zithromax Z-pak as directed
Symptomatic relief with OTC medications.
Plenty of fluids.
Recheck if there are worsening symptoms, such as a higher fever, shortness of breath, or chest pain.
