Comprehensive Patient Profile – Chronic Conditions – Acute Problem – HPI
# CHIEF COMPLAINT: [select name="variable_16" value="***|A|Abdominal Pain|Alcohol Withdrawal|Altered Mental Status / Confusion|B|Bilateral Leg Pain|C|Chronic Obstructive Pulmonary Disease (COPD)|Confusion / Altered Mental Status|D|Diabetes Mellitus|E|Ethanol abuse|F|G|H|Headache|I|Intractable Headache||Intractable Back Pain|J|K|L|Left Leg Pain|M|N|O|P|Paresthesia|Pulmonary Exacerbation Secondary To Cystic Fibrosis|Q|R|Right Leg Pain|S|Shortness of Breath (SOB)|Shortness of Breath (SOB) Secondary To Congestive Heart Failure Exacerbation|Shortness of Breath (SOB) Secondary To Suspected Congestive Heart Failure Exacerbation|Sickle Cell Crisis|T|Type I Diabetes|Type II Diabetes|U|V|Vaso-Occlusive Crisis|W|X|Y|Z"] # Patient is a [select name="variable_01" value="***|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100"] year old [select name="variable_02" value="***|female|male|lady|gentleman|man|woman|boy|girl|female toddler|male toddler|female infant|male|infant"] [select name="variable_17" value="***|who presents with a chief complaint of|who is presenting with|who was admitted for|who was electively admitted for evaluation of|who comes in to the office for follow up of|who comes in to the office for follow up for|who presents via telemedicine for follow up of|who presents via telemedicine for follow up for"] [select name="variable_16" value=""] with a relevant past medical history significant for [checkbox name="variable_18" value="***|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___"]. Other significant but non-pertinent past medical history includes: [textarea name="variable_1" default="nothing else in particular"] ================= | 1. SUBJECTIVE | ================= # Patient states that they were was in their usual state of health until "[text name="variable_10" default=""]" # Patient seen and examined this morning. [select name="variable_26" value="***|No overnight events.|Patient was in their usual state of health until ***| "] # Patient [select name="variable_05" value="***|denies any acute complaints"]. # Patient [select name="variable_06" value="***|denies any general improvement since admission|denies any general improvement since yesterday|endorses a general improvement since admission|endorses a general improvement since yesterday|continues to deny any general improvement since admission|continues to endorse a general improvement from admission|continues to endorse generalized pain without any significant improvement from yesterday"]. # Patient [checkbox name="variable_19" value="***|ATTESTS TO|ABDOMINAL PAIN|CHEST PAIN|NAUSEA|SHORTNESS OF BREATH|VOMITING|"][checkbox name="variable_08" value="***|Patient denies any|abdominal pain|chest pain|nausea|shortness of breath|vomiting|"]. # Patient is currently is *** in pain**"[text name="variable_11" default=""]" and rated a "[text name="variable_12" default=""]" out of 10. - The pain is described as " dull " - The pain is described as " sharp " - The pain is described as " crampy " - The pain is described as " an ache " - The pain is described as " X " ——---------------------——-- | REVIEW OF SYSTEMS (ROS) | —-----------------------——- Constitutional [checkbox name="variable_1" value="***|No complaints of fever or chills|! COMPLAINS OF CHILLS. No complaints of fever|! COMPLAINS OF FEVER. No complaints of chills.|! COMPLAINS OF FEVER & CHILLS."] Eyes [checkbox name"variable_2" value="***|No complaints of itching or burning|! COMPLAINS OF BURNING. No complaints of itching|! COMPLAINS OF ITCHING. No complaints of burning.|! COMPLAINS OF ITCHING & BURNING."] Ears, Nose, & Throat [checkbox name"variable_2" value="***|- No complaints of sore throat or nosebleeds|- No complaints of sore throat. ! COMPLAINS OF NOSEBLEEDS|! COMPLAINS OF SORE THROAT. No complaints of nosebleeds|! COMPLAINS OF SORE THROAT & NOSEBLEEDS. Respiratory [checkbox name"variable_3" value="***|No complaints of shortness of breath or wheezing.|- No complaints of shortness of breath. ! COMPLAINS OF WHEEZING|! COMPLAINS OF SHORTNESS OF BREATH. No complaints of wheezing|! COMPLAINS OF SHORTNESS OF BREATH & WHEEZING."] Cardiovascular [checkbox name"variable_4" value="***|No complaints of chest pain or edema.|No complaints of chest pain.|! COMPLAINS OF EDEMA.|! COMPLAINS OF CHEST PAIN. No complaints of edema.|! COMPLAINS OF CHEST PAIN & EDEMA."] Gastrointestinal [checkbox name"variable_2" value="***|No complaints of diarrhea or abdominal pain.| No complaints of diarrhea. COMPLAINS OF ABDOMINAL PAIN LOCALIZED TO (***).|COMPLAINS OF DIARRHEA (***# of times). No complaints of abdominal pain.| COMPLAINS OF DIARRHEA (***# of times) & ABDOMINAL PAIN LOCALIZED TO (***)."] Genitourinary [checkbox name"variable_5" value="***|No complaints of discharge, hematuria, or burning with urination|! COMPLAINS OF|VAGINAL DISCHARGE|PENILE DISCHARGE|HEMATURIA|BURNING WITH URINATION||Denies|vaginal discharge|penile discharge|hematuria|burning with urination"] Musculoskeletal [checkbox name"variable_28" value="***|No complaints of weakness, decreased range of motion, or back pain|! COMPLAINS OF|BACK PAIN|WEAKNESS IN LEFT ARM|WEAKNESS IN LEFT LEG|WEAKNESS IN RIGHT ARM|WEAKNESS IN RIGHT LEG|WEAKNESS IN UPPER EXTREMITIES BILATERALLY|WEAKNESS IN LOWER EXTREMITIES BILATERALLY||Denies|back pain|weakness in left arm|weakness left leg|weakness in right arm|weakness in right leg|weakness in upper extremities bilaterally|weakness in lower extremities bilatterally Hematology & Lymph Nodes [checkbox name"variable_27" value="***|No complaints of bleeding or bruising|! COMPLAINS OF|BLEEDING|BRUISING||Denies|bleeding|bruising"] Immunologic [checkbox name"variable_11" value="***|No complaints of rhinorrhea, sneezing, fever, or chills|! COMPLAINS OF|RHINORRHEA|SNEEZING|FEVER|CHILLS||Denies|rhinorrhea|sneezing|fever|chills"] Endocrinology [checkbox name"variable_14" value="***|No complaints of thirst, night sweats, significant weight gain or weight loss|! COMPLAINS OF|THIRST|NIGHT SWEATS|SIGNIFICANT WEIGHT GAIN|SIGNIFICANT WEIGHT LOSS|Denies|thirst|night sweats|significant weight gain|significant weight loss|significant weight gain or weight loss"] Dermatological [checkbox name"variable_8" value="***|No complaints of rashes, lesions, or ulcerations|! COMPLAINS OF|SKIN RASH|A LESION|LESIONS||Denies|skin rash|lesions"] Neurological [checkbox name"variable_9" value="***|No complaints of numbness, tingling, or headache|! COMPLAINS OF|NUMBNESS|TINGLING|HEADACHE||Denies|numbness|tingling|headache"] Psychiatric [checkbox name"variable_13" value="***|No complaints of anxiety, depression, suicidal ideation or homicidal ideation|! COMPLAINS OF|ANXIETY|DEPRESSION|SUICIDAL IDEATION|HOMICIDAL IDEATION||Denies|anxiety|depression|suicidal ideation|homicidal ideation"] ================= | 3. ASSESSMENT | ================= Patient is a [select name="variable_01" value=""] year old [select name="variable_02" value=""] hospital day [select name="variable_29" value=""] [select name="variable_17" value=""] [select name="variable_03" value=""] with a past medical history significant for [checkbox name="variable_18" value=""]. =========== | 4. PLAN | =========== [select name="variable_31" value="|# "][checkbox name="variable_32" value="|A|# Abdominal Pain - |# Abdominal Pain - Improving - |# Abdominal Pain - Resolved - |# Acute Kidney Injury (AKI) - |# Acute Kidney Injury (AKI) - Improving - |# Acute Kidney Injury (AKI) - Resolved - |# Alcohol Withdrawal Syndrome With Complications - |Alcohol Withdrawal Syndrome Without Complications - |Anasarca - |Anemia of Chronic Disease - |Anxiety - |Avascular Necrosis of the *** - |B|Bacterial Vaginosis (BV) - |Bacteriuria - |Bipolar Disorder - |C|Chronic Abdominal Pain - |Chronic Anemia - |Chronic Obstructive Pulmonary Disease (COPD) - |Cough - |Cystic Fibrosis - |D|E|F|Failure to Thrive - |G|H|History of Cerebrovascular Accident - |History of Herpes Simplex Virus (HSV) = |History of Prolonged QTc - |History of Prolonged QTc - Resolved - |History of Substance Abuse - |History of Tobacco Use - |Hyperkalemia - |Hypertension -|Hypernatremia - |Hyperlipidemia - |Hypokalemia - |Hyponatremia - |I|J|K|L|M|N|O|P|Polysubstance Abuse - |Peripheral Edema - |Pseudo-Hyponatremia - |Q|R|Rash -|S|Sacral Decubitus Ulcer - Grade I -|Sacral Decubitus Ulcer - Grade II - |Sacral Decubitus Ulcer - Grade III - |Sacral Decubitus Ulcer - Grade IV - |Sickle Cell Anemia - |Sickle Cell Vaso-Occlusive Crisis - |T|Tobacco Use - |Type II Diabetes - |Type I Diabetes - |U|Urinary Tract Infection (UTI) - |V|Vaginal Discharge - |Vaso-Occlusive Crisis - |W|X|Y|Z"] Subjectively, patient .......... Objectively, ....... My assessment is that ...... Thus our short term goal in management will be to: Our long term goal in management will be to: Therefore, our plan for today is to:..... . Physical examination revealed ............... and .......... suggestive of ...........The most likely cause of patient’s ...... is....These symptoms could also be explained by ............ ......... and ..... are risk factors. However, ....... usually causes ....... which makes ..... an unlikely cause for these symptoms. We will begin addressing this patients condition by first ....... followed by ..... [select value="|Therefore, the plan for today is:|Plan for today is:"] [textarea name="variable_12" default=""]
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