Ped Endo Clinic Note

Pediatric Endocrinology Clinic Note
Consultant: [textarea cols=40 rows=1 default="Dr."]
Date: [date name="variable_1" default="07-28-2022"]
Patient accompanied by: [select name="Q1" value="mother|father|mother,father"][text default="_"]
___________________________________

Chief Complaint: [textarea cols=40 rows=1 default="***"]

In Summary:

This is a [textarea cols=5 rows=1 default=" 1"] [select value="y/o|m/o"] [select value="F|M"] , [textarea cols=60 rows=1 default=" previously healthy. ***with _"].
The patient [select value="was referred to our clinic for evaluation of|is presenting to endocrine clinic for follow-up for"] [textarea cols=60 rows=1 default=" ***. Last seen on _"].
___________________________________

Subjective:
-

[textarea cols=60 rows=1 default="-PMhx: unremarkable. Born FT_, BW: _, "]
[checklist name="98" value="severe asthma, recurrent infections, chronic illness, or recurrent hospitalizations | prolonged or frequent use of glucocorticoids, or use of ADHD medication|neonatal hypoglycemia, prolonged jaundice, microphallus, or traumatic delivery |cranial radiation, head trauma, or hx of CNS infections|developmental delay/learning disabilities|meeting all developmental milestones"]
-PShx: [textarea cols=60 rows=1 default="none"]
-Meds: [textarea cols=60 rows=1 default="none. _"]
-Fhx:[textarea cols=60 rows=2 default="unremarkable. Mother is _cm tall and menarche at _yrs, father is _cm tall, and growth spurt at _yrs."] 
[checklist value="family hx of short stature/growth problem|family hx of delayed puberty"]
-ROS:
[checklist name="99" value="poor appetite/caloric intake|weight loss/poor weight gain|abdominal pain|neusea/vomiting|diarrhea|constipation|polyuria/polydipsia.|heat or cold intolerance|skin/hair changes|headache|vision changes|fatigue|fever|arthralgia|rashes|lymphadenopathy"]
___________________________________

Clinical Exam [textarea cols=60 rows=1 default="( done in presence of _, with patient/guardian permission)"].
[textarea cols=60 rows=2 default="GEN: Awake, alert and oriented. No acute distress. vitals reviewed. Healthy appearing, hydrated and nourished."]
[textarea cols=60 rows=1 default="HEAD: atraumatic, normocephalic."]
[textarea cols=60 rows=2 default="ENT: Moist mucus membranes. Normal eyes, conjunctiva clear. No abnormal eye movement."]
[textarea cols=60 rows=2 default="NECK: Thyroid is _ in size, no goiter. no nodules or tenderness. no cervical lymphadenopathy."]
[textarea cols=60 rows=1 default="PULM/CVS: Regular rate, no tachypnea or no increase WOB."]
[textarea cols=60 rows=2 default="ABDOMEN: soft, non-tender, non-distended, no organomegaly or masses. _no striae."]
[textarea cols=60 rows=3 default="NEURO/MSK:Alert, no focal findings, PERRL, _ optic disc, deep tendon reflexes normal and symmetric, muscle tone and strength normal, gait normal, no tremors. No scoliosis."]
[textarea cols=60 rows=2 default="SKIN: warm, well perfused, no rashes or birth marks, _acanthosis."]
[textarea cols=60 rows=2 default="GU: normal female, no enlarged clitoris. _normal male, testes (Rt: _ml, Lt:_ml. SPL:_cm)."]
Tanner stage:
-T[select value="1|2|3|4|5"] pubic hair
-T[select value="1|2|3|4|5"] [select value="breast|testes"]

Growth parameters:
-Current height Z score: [textarea cols=5 rows=1 default="_"]
[textarea cols=60 rows=1 default="-Weight _ percentile, BMI _percentile"]
[textarea cols=60 rows=1 default="-Arm span _cm"]
[textarea cols=60 rows=1 default="-Upper segment (sitting height = _), US/LS ratio"]
-Growth velocity:[textarea cols=60 rows=1 default=" _ cm/yr in the last _"]
[textarea cols=60 rows=1 default="-Growth curve description: _"]
[textarea cols=60 rows=1 default="-Mom: _ cm(measured in clinic)"]
[textarea cols=60 rows=1 default="-Dad: _ cm (per mother report)"]
[textarea cols=60 rows=1 default="-MPH:_ ±8.5cm"]
[textarea cols=60 rows=4 default="-Bone age (my reading): _. Delayed or advanced bone age. 2SD above_below mean. BA-CA of approximately 12 months between 2 and 4 years, 18 months between 4 and 12 years, and 24 months after age 12."]
___________________________________
Lab/imaging review and interpretation 
[textarea name="variable_1" default="none"]

___________________________________
Impression/plan:
This is a [textarea cols=5 rows=1 default=" 1"] [select value="y/o|m/o"] [select value="F|M"] ,[textarea cols=60 rows=1 default="with ***"].

Problems addressed today
[textarea cols=60 rows=2 default="#Short Stature"]
[textarea default="1- Labs:  
2- Imaging: 
3- Medication: none
4- Counseled about: 
5- Referral: none
6- Follow up: in ***."]
___________________________________
[textarea default="Counseled family at length about our impression, and explained diagnosis, lab results, and management plan. All questions were fully answered. Family verbalized understanding and agreement with the plan of care."]
Pediatric Endocrinology Clinic Note
Consultant:
Date:
Patient accompanied by:
___________________________________

Chief Complaint:

In Summary:

This is a , .
The patient .
___________________________________

Subjective:
-



-PShx:
-Meds:
-Fhx:

-ROS:

___________________________________

Clinical Exam .









Tanner stage:
-T pubic hair
-T

Growth parameters:
-Current height Z score:



-Growth velocity:





___________________________________
Lab/imaging review and interpretation


___________________________________
Impression/plan:
This is a ,.

Problems addressed today


___________________________________

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.27, 49 form elements, 53 boilerplate words, 1 text boxes, 35 text areas, 1 dates, 3 check lists, 9 drop downs, 70 total clicks
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