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Christina
Clinic note
Christina is a 2 year old female, known to our
practice since birth, brought by mother for cold and cough with
fever
Temp. at home = 102 x 2 days
No fever this morning
Mother noted yellow discharge fr. right eye this morning
Eating and drinking well
No ear pain, sore throat or rash
No sick contacts
No vomiting or diarrhea
Physical exam:
Overall:
Alert child.
Tympanic
membranes:
normal.
Throat:
mild erythema.
Lungs:
clear.
Heart:
regular
rate-rhythm w/ no murmurs.
Eyes:
mild conjunctival infection bilaterally w/ discharge from right eye
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