Very specific dr notes?!
Question: Could anyone tell me what these mean? I was just lookinmg at my notes online from today's visit
General: Pt appears in NAD
Ears: TMs with nl landmarks.
Nose: Swollen, boggy mucous membranes with mucopurulent discharge
Face: sinus tenderness to palpation
Mouth: Teeth, gums, tongue, soft palette- WNL, pharynx mildly erythematous with purulent post nasal drip, no exudates
Neck: Supple, shoddy cervical adenopathy.
Chest: CTA, no wheeze
Heart: RRR, no murmurs, rubs or gallops
Answers: Could anyone tell me what these mean? I was just lookinmg at my notes online from today's visit
General: Pt appears in NAD
Ears: TMs with nl landmarks.
Nose: Swollen, boggy mucous membranes with mucopurulent discharge
Face: sinus tenderness to palpation
Mouth: Teeth, gums, tongue, soft palette- WNL, pharynx mildly erythematous with purulent post nasal drip, no exudates
Neck: Supple, shoddy cervical adenopathy.
Chest: CTA, no wheeze
Heart: RRR, no murmurs, rubs or gallops
General: Patient appears in no acute distress
Ears: Tympanic membranes (eardrums) with normal landmarks
Nose: Swollen, Boggy mucous membranes with mucopurulent discharge (you have a runny nose)
Mouth: Teeth, gums, tongue, soft palette within normal limits, pharynx (back of the throat) mildly erythemrtous (reddened) with purulent post nasal drip, no exudates (runny nose is running down the throat)
Neck: Supple (flexible), shoddy (small but palpable - probably fighting an infection) cervical (along the neck) adenopathy (enlarged) - just means that your lymph nodes along the side of you neck are slightly enlarged probably because your body is fighting an infection
Chest: Clear to ausculation (listening with a stethoscope), no wheeze (an abnormal sound that is an obstructed small airway, makes a whistling sound)
Heart: regular rate and rhythm, no murmurs (caused by faulty heart valves), no rubs (noise made when lung structures rub together) and no gallops (irregular heart sound)
All together this exam reveals a possible sinus infection, possibly viral, causing your sinuses to produce excess mucous that is running down the throat. This can cause sinus pain and pressure as well as a sore throat. Your lymph nodes are slightly enlarged because your body is fighting the infection. Otherwise your exam is perfectly normal. Drink plenty of fluids to thin the secretions, get plenty of rest to let your body fight the infection and recover, you can run a humidifier to moisten secretions, and if you have no other health problems you could take an over the counter cold or sinus medicine. You may want to ask the pharmacist for a medication with a decongestant in it. These are over the counter but are regulated by the pharmacy because they have been abused by some people in the past. Hope you get to feeling better!
NAD - no apparent distress
PT = patient(you)
WNL - within normal limits
CTA - clear to auscultation(your lungs sounded OK )
RRR-regular rhythm and rate
mucopurulent discharge - yellow thick snot from your shnase.
neck: he is referring to your lymphnodes being swollen form your cold.
erythematous means your throat is red and in flamed