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[checkbox name="historian" value="history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]

CC:
[checkbox name="cc" value="headache|fever|malaise|fatigue|body aches|night sweats|runny nose|nasal congestion|PND|sinus pain|earache/ear pressure|sore throat|hoarseness|cough|chest tightness/pain w/ breathing|"][textarea cols=50 rows=5]

HPI:
Problem:
[checkbox name="new_chronic" value="new problem|chronic condition|acute exacerbation of chronic condition|"][textarea cols=50 rows=1]
Duration:
[checkbox name="duration" value="started today|started yesterday|started several days ago|started more than 1 week ago||hours|days|weeks|months|years"][textarea cols=50 rows=1]
Symptoms:
[checkbox name="sx" value="still present|increasing in severity|persisting|occasional|decreasing|resolved|"][textarea cols=50 rows=1]

RECENT HISTORY: [+] reported [-] not reported
[checkbox name="recent" value="ER/UC visit|hospitalization/surgery/procedure|travel|sick contact|new/changed medications|antibiotic use|asthma/COPD|smoker|immunosuppression|"][textarea cols=50 rows=5]
MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="taking OTC|taking RX|not helping|not reporting any|"][textarea cols=50 rows=3]

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated
EYES:
[checklist name="eye_symptoms" value="decrease in vision|redness/irritation|discharge|lid swelling|pain with EOM"][textarea cols=50 rows=3]
MOUTH:
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache"][textarea cols=50 rows=3]
NECK:
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"][textarea cols=50 rows=3]
CV:
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"][textarea cols=50 rows=3]
GI:
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|bloating|abdominal pain|constipation|diarrhea"][textarea cols=50 rows=3]
GU:
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|odor|hematuria|hesitancy|retention|nocturia|oliguria|incontinence|itching|discharge|genital lesions"][textarea cols=50 rows=3]
MSK:
[checklist name="msk_symptoms" value="neck pain|back pain|chronic pain/meds|localized joint pain/deformity|localized muscle/soft tissue pain/swelling"][textarea cols=50 rows=3]
NEURO:
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"][textarea cols=50 rows=3]
PSYCH:
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"][textarea cols=50 rows=3]
LYMPH/HEMA/IMMUNE:
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|autoimmune dz|h/o cancer"][textarea cols=50 rows=3]
DERM:
[checklist name="derm_symptoms" value="pruritus|rash|hives|redness|swelling|wounds|new or suspicious lesions"][textarea cols=50 rows=3]


Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB|crying but consolable|speaking in full sentences||ill-appearing|tired-looking|short of breath|diaphoretic||drowsy|appears impaired|slumped||heavy built|muscular|lean|well-nourished|frail|"][textarea cols=50 rows=3]

Skin:
[checkbox name="skin" value="warm, dry|grossly intact, no rashes|no bruises|normal turgor|dry||tattoos|body piercings||pallor|cyanosis|poor turgor|diaphoresis|rash|"][textarea cols=50 rows=3]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|symmetrical face|CN grossly intact|"][textarea cols=50 rows=3]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact||conjunctival injection|epiphora|conjunctival exudate||allergic shiners|dennie lines||palpebral edema|palpebral exudates||glasses|contacts|"][textarea cols=50 rows=3]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|no mastoid tenderness||clear canals without erythema or discharge|TMs normal in appearance||tragal tenderness|swelling of external auditory canal|pustule in canal|cerumen in canal|TM obscured by cerumen||HOH|hearing aid(s)||TM red|TM bulging|TM perforated||TM retracted|fluid behind TM|tube in TM||mastoid tenderness|"][textarea cols=50 rows=3]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness||deviated septum||mucosal edema|clear discharge|purulent drainage|"][textarea cols=50 rows=3]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture|poor dentition|tooth decay||single oral ulcer|multiple oral ulcers|gum swelling|"][textarea cols=50 rows=3]

Throat:
[checkbox name="throat" value="normal voice|no stridor|patent pharynx w/o swelling or exudates|uvula midline||hoarseness|inspiratory stridor|muffled voice||vesicles on soft palate|petechiae on soft palate||pharyngeal erythema w/o exudates|pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules|"][textarea cols=50 rows=3]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no masses noted|no LAD||anterior LAD|posterior LAD|"][textarea cols=50 rows=3]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|chest wall atraumatic and non-tender|no retractions|clear and equal breath sounds bilaterally|no axillary or supraclavicular LAD||respiratory distress|breath sounds decreased bilaterally|coughing|poor effort||expiratory wheezing|crackles|"][textarea cols=50 rows=3]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema||tachycardia|irregular heart rhythm|systolic murmur||ankle edema|varicosities|stasis discoloration|calf tenderness|"][textarea cols=50 rows=3]

Abdomen:
[checkbox name="abd" value="not examined|normal visual inspection|no distension|protruding||normal bowel sounds|soft|non-tender||guarding|diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness||hypoactive bowel sounds|hyperactive bowel sounds||surgical scar|umbilical hernia|colostomy in situ|"][textarea cols=50 rows=3]

GU:
[checkbox name="gu" value="not examined|no suprapubic tenderness|no CVAT bilaterally||normal external genitalia|circumcised|uncircumcised||no inguinal LAD|no urethral discharge|"][textarea cols=50 rows=3]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age|"][textarea cols=50 rows=3]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|ambulates w/o limp or alteration in gait||extremities strong w/o atrophy|no gross motor deficits|sensation symmetrical & grossly intact||no involuntary movements or tremor||tardive dyskinesia|tics|"][textarea cols=50 rows=3]

Speech/Vocalization:
[checkbox name="speech" value="normal for age|clear & coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks|"][textarea cols=50 rows=1]

Behavior/Psychomotor Activity:
[checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history & exam||guarded|anxious|irritable|frustrated|labile||agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles||grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=1]

OFFICE DIAGNOSTICS:
[checkbox name="office" value="none||rapid strep NEG|rapid strep POS|rapid flu NEG|rapid flu POS|CXR|"][textarea cols=50 rows=3]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|previous visits|previous laboratory/diagnostic studies|"][textarea cols=50 rows=3]

[comment memo="Dx:
viral syndrome
influenza
rhinitis
sinusitis
otitis media
otitis externa
laryngitis
tonsillitis
pharyngitis
dyspnea
acute bronchitis
acute bronchospasm"]


A/P:
[textarea cols=50 rows=5]

PLAN OF CARE:
[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

RX:
[checkbox name="rx" value="OTC|paper|electronic|given to MA to be transmitted to pharmacy|none|"][textarea cols=50 rows=3]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs,exam findings, recommendations, reporting medication side effects to clinic immediately, appropriate follow up with PCP|rest/hydration|proper/timely abx use|"][textarea cols=50 rows=3]

BARRIERS TO CARE:
[checkbox name="barriers" value="incomplete history d/t poor effort|incomplete history d/t cognitive changes|incomplete history d/t distress/affect|incomplete history d/t language barrier||vague shifting complaints||history not supported by objective findings|supporting documentation unavailable||incomplete exam d/t safety concerns|poor cooperation with exam||multiple comorbidities|polypharmacy|poor compliance with POC|intolerance of/therapeutic failure on multiple meds||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others||lack of motivation|negative attitude to diagnostic impression & proposed tx|lack of interest in nonpharmacologic therapies||psychiatric comorbidity|h/o alcohol/substance abuse|victim of abuse|social/cultural barriers||altered mental status|affect|hostile/disruptive behavior|"][textarea cols=50 rows=1]

FOLLOW UP/DISPOSITION:
[checkbox name="disposition" value="RTC or see PCP as discussed, sooner if condition worsens/persists or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx||RTC 24 hours|RTC 48 to 72 hours|RTC 1 week||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]


CC:


HPI:
Problem:

Duration:

Symptoms:


RECENT HISTORY: [+] reported [-] not reported

MEDICATIONS:
allergies reviewed


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated
EYES:

MOUTH:

NECK:

CV:

GI:

GU:

MSK:

NEURO:

PSYCH:

LYMPH/HEMA/IMMUNE:

DERM:



Appearance:


Skin:


Head/Face:


Eyes:


Ears:


Nose:


Mouth:


Throat:


Neck:


Chest/Lungs:


CV:


Abdomen:


GU:


MSK:


Neuro:


Speech/Vocalization:


Behavior/Psychomotor Activity:


OFFICE DIAGNOSTICS:


REVIEWED:


Dx:
viral syndrome
influenza
rhinitis
sinusitis
otitis media
otitis externa
laryngitis
tonsillitis
pharyngitis
dyspnea
acute bronchitis
acute bronchospasm



A/P:


PLAN OF CARE:


RX:


INSTRUCTED ON:


BARRIERS TO CARE:


FOLLOW UP/DISPOSITION:

Result - Copy and paste this output:

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