Chapter 5: The Lymphatic and Immune Systems | Kim Lee's Chart Note

CHART NOTE

Patient Name: Lee, Kim
ID Number: KL7214
Examination Date: May 14, 20xx

SUBJECTIVE
This 9-year-old patient presents with chronic nasal congestion, sore throat, and enlarged tonsils. Mother states that Kim always breathes through her mouth and snores at night. Also, mother said it is getting to the point where she is having difficulty understanding her since word formation is poor. Patient has a chronic history of strep throat.

OBJECTIVE
Temperature is 101. Tympanic membranes are clear. Exam of the pharynx reveals markedly enlarged tonsils, almost touching. Erythema is present. Nasal mucosa is edematous. Neck is supple without lymphadenopathy. Chest is clear.

ASSESSMENT
Tonsillitis and probable hypertrophy of the adenoids.

PLAN
Refer to ENT (ear, nose, and throat specialist) for possible tonsillectomy and adenoidectomy.