CHART NOTE
PHYSICAL EXAMINATION
Ear canals are clear. Tympanic membranes are normal. Nasal airway is adequate. Septum slightly deviated to the right. No discharge. Throat reveals normal mucous membrane. No evidence of inflammation. No PND (postnasal drainage). She does have a couple of little lymphoid plaques, both in the pharynx and in the area where tonsils were removed. These are not neoplasms and not presently inflamed, just a tiny bit juicy. Neck reveals no adenopathy. Thyroid and trachea are normal.
IMPRESSION
Very mild lymphoid hyperplasia of the tonsillar fossae postoperative and the nasopharynx.
DISPOSITION
Reassured, explained what is going on, and she is to return p.r.n. Encouraged her not to take antibiotics for just every sore throat.
FOOTNOTE
Line 7. Exam was expanded to Examination in the report.
Line 11. The abbreviation PND was expanded to postnasal drainage in this report.
Line 18. Fossas was changed to fossae, plural of fossa.
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