Presenting with fussiness and bilateral ear tugging

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What to document for HEENT ROS for 15 month old white female presenting with fussiness and bilateral ear tugging starting 5 days ago. She is also experiencing a productive cough that is worse at night, rhinorrhea, congestion, is eating less, and is waking up screaming a few times a night. She was sent home yesterday from daycare due to having a 102.2 fever. The patient has been given tylenol and motrin as needed for the symptoms, but they have offered no notable relief. The grandfather reports that the symptoms are causing significant stress for him and his family, because she can not not return to daycare until she is fever-free forcing the them to miss work to stay home and care for her.The grandfather states the the patient has never experienced symptoms like this before, especially the ear tugging. There has been no noticeable ear discharge or dyspnea ?

Reference no: EM133805176

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