Acute soap 2 Nina

ID:[text name="identification" default=" "]
Accompanied by:[text name="accompanied" default=" "]

CC:[text name="CC" default=" "]

HPI:[textarea name="hpi" default=" "]

PMHx:[text name="pmhx" default=" "]

ALLERGIES:[checkbox name="allergies_check" value="NKDA"][text name="allergies" default=" "]

MEDS: [text name="meds" default=" "]

HOSPITALIZATIONS: [text name="hospitalizations" default=" "]

SURGERIES: [text name="surgeries" default=" "]

IMMUNIZATIONS: [text name="immunizations" default="up to date"]

FHx: [textarea name="fhx" default=" "]

SHx: [textarea name="shx" default=" "]

ROS:

-Constitutional: [checkbox name="ros_constitutional_check" value="Denies fever|Denies chills|Denies night sweats|Denies fatigue|Denies changes in weight"][text name="ros_constitutional" default=" "]
-HEENT: [checkbox name="ros_heent_check" value="Denies vision changes|Denies ear pain|no nasal congestion|Denies sore throat|Denies cough"][text name="ros_heent" default=" "]
-Cardiovascular: [checkbox name="ros_cardio_check" value="Denies chest pain|Denies palpitations|Denies swelling of extremities"][text name="ros_cardio" default=" "]
-Respiratory:[checkbox name="ros_resp_check" value="Denies SOB|Denies hemoptysis|Denies dyspnea"][text name="ros_resp" default=" "]
-GI: [checkbox name="ros_gi_check" value="Denies change in appetite|Denies abdominal pain|Denies hematemasis|Denies hematochezia|Denies N/V/D|Nausea|Vomiting|Diarrhea"][text name="ros_gi" default=" "]
-GU: [checkbox name="ros_gu_check" value="Denies urinary frequency|Denies urinary urgency|Denies dysuria|Denies hematuria|Denies leakage of urine"][text name="ros_gu" default=" "]
-MSK: [checkbox name="ros_msk_check" value="Denies back pain|Denies joint pain|Denies muscle aches"][text name="ros_msk" default=" "]
-Skin: [checkbox name="ros_skin_check" value="Denies rash|Denies bruising|Denies lesions"][text name="ros_skin" default=" "]
-Neuro: [checkbox name="ros_neuro_check" value="Denies headache|Denies dizziness|no syncope"][text name="ros_neuro" default=" "]
-Psych: [checkbox name="ros_psych_check" value="denies SI/HI|Denies hallucination|Denies depression|Denies anxiety"][text name="ros_psych" default=" "]
-Endocrine: [checkbox name="ros_endo_check" value="Denies heat/cold intolerance|Denies excessive thirst|Denies polyuria"][text name="ros_endo" default=" "]
-Hematologic: [checkbox name="ros_heme_check" value="Denies excessive bruising|Denies excessive bleeding|Denies painless lymph node enlargement"][text name="ros_heme" default=" "]
-Allergy/Immuno: [checkbox name="ros_allergyimmuno_check" value="itchy eyes|sneezing"][text name="ros_allergyimmuno" default=" "]

PHYSICAL EXAM:

-Vitals:[text name="pe_vitals" default=" "]
-General: [checkbox name="pe_general_check" value="WDWN|Well appearing|in no acute distress|overweight|obese"][text name="pe_general" default=" "]
-HEENT: [checkbox name="pe_heent_check" value="PERRLA|white sclera|conjuntica pink|ears patent|TM intact|Wax present|erythematous pharynx| normal pharynx|TM bulging|TM retracted|TM Perf|Serous fluid present"][text name="pe_heent" default=" "]
-Cardiovascular: [checkbox name="pe_cardio_check" value="normal S1 S2|RRR|No murmurs, rubs, gallops|no carotid bruits|no edema|peripheral pulses intact|no cyanosis|capillary refill < 2 seconds"][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="CTA bilaterally|no rales, rhonchi, wheezes|no retractions|no accessory muscles being used|wheezing|upper respiratory congestion"][text name="pe_resp" default=" "]
-GI:[checkbox name="pe_gi_check" value="BS present in all 4 quadrants|abdomen soft/nontender to palpation|nondistended|No rigidity|no guarding|no masses"][text name="pe_gi" default=" "]
-GU: [checkbox name="pe_gu_check" value="No CVA tenderness|no suprapubic pain"][text name="pe_gu" default=" "]
-MSK: [checkbox name="pe_msk_check" value="normal ROM|no pain on palpation|strength 5/5 in all extremities"][text name="pe_msk" default=" "]
-Skin: [checkbox name="pe_skin_check" value="no rash|no lesion|no discoloration"][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_neuro_check" value="Grossly oriented X 4|gait WNL|sensation intact|normal reflexes"][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_psych_check" value="Pleasant, calm and cooperative|Judgement and insight intact|thought process normal|normal affect"][text name="pe_psych" default=" "]
-Hematologic: [checkbox name="pe_heme_check" value="cervical lymphadenopathy|no lymphadenopathy|no tenderness or masses palpated|no bruises"][text name="pe_heme" default=" "]

Ddx:
[text name="dx1" default="1."]
[text name="dx2" default="2."]
[text name="dx3" default="3."]
[text name="dx4" default="4."]

ASSESSMENT/PLAN:
[textarea name="anp" default="1."]
[comment memo="Don't forget pt education and F/U"]

Dispo and Education
        1)	Diagnostic: UDS collected
        2)	Treatment: refills as above
	3)	Education: on POC and appropriate use of meds 
Report adverse symptoms such as heart palpitations, chest pain, palpitations and go to nearest ER
	4)	Consultation, Collaboration or Referral: None
	5)	Follow-up: schedule F/U 1 month. RTC for any concerns. ER red flags given.