URI – Sore throat, Cough

[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=1]

CC: [checkbox name="cc" value="headache|fever|malaise|fatigue|body aches|night sweats||runny nose|nasal congestion|PND|sinus pain|loss of smell/taste|earache/ear pressure|sore throat|hoarseness||cough|chest tightness/pain w/ breathing||recent travel|contact with suspected/confirmed c19 case|sx suggestive of C19|c19 requested by employer||recent c19 POS test|recent c19 NEG test||recent ER/UC visit||no sx|"][textarea cols=50 rows=5]

HPI/SYMPTOMS: [checkbox name="hpi" value="started today|started yesterday|started several days ago|started more than 1 week ago|started months ago|started years ago||still present|increasing in severity|persisting|occasional|decreasing|resolved||as in cc|"][textarea cols=50 rows=3]

MEDICATIONS: allergies reviewed, [checkbox name="medications" value="taking OTC|taking RX||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages|unable to name medications/reasons/dosages||none reported|"][textarea cols=50 rows=3]


REVIEW OF SYSTEMS: negative except as stated in HPI
General:[textarea name="variable_5" default=" does not report fever, chills, fatigue, malaise, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headaches, vision changes, eye redness/discharge, pain with EOM, facial swelling, earache, ringing, ear discharge, nasal congestion, rhinorrhea, mouth sores, changes in taste, sore throat, neck swelling"]
CV:[textarea name="variable_7" default=" does not report chest pain, SOB, palpitations, fainting, or ankle swelling"]
Pulmonary:[textarea name="variable_8" default=" does not report shortness of breath, cough, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, or diarrhea"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, discharge, or bleeding"]
MSK:[textarea name="variable_11" default=" does not report myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, tremor, balance problems, weakness, or falls"]
Psychiatric:[textarea name="variable_14" default=" does not report depression, anxiety, mood swings, memory loss, or insomnia"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, hair loss, swelling, or wounds"]
Endocrine:[textarea name="variable_15" default=" does not report polyphagia, polydipsia, night sweats, hot flashes, or heat/cold intolerance"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]

-------------------------------------

OFFICE DIAGNOSTICS: [checkbox name="office" value="none||rapid strep NEG|rapid strep POS||rapid flu NEG|rapid flu POS||rapid C19 antigen NEG|rapid C19 antigen POS||rapid C19 antibody NEG|rapid c19 antibody POS||CXR|"][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: [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||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="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||not examined|"][textarea cols=50 rows=3]
GU: [checkbox name="gu" value="no suprapubic tenderness|no CVAT bilaterally||normal external genitalia||not examined|"][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]


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


Discussion:
[textarea cols=50 rows=5]

REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, [checkbox name="instructions" value="previous visits|laboratory/diagnostic studies|specialty consults|hospital visits||medications|PMP|reporting medication side effects immediately|medication compliance|bringing all medications/labels to all visits||home BP checks|home BS checks|daily weights||controlling chronic conditions|age- and disease-appropriate screening and immunization||lifestyle modification, including: diet, avoiding/limiting alcohol, limiting sugar/carbs, limiting high fat intake, liming salt intake, staying active/daily physical activity/exercise, wt maintenance, stress reduction, sleep hygiene||alcohol cessation|smoking cessation||NSAIDs prn|cognitive restructuring in managing chronic conditions|symptom exacerbation through rebound mechanism|risks of respiratory depression with polypharmacy|"][textarea cols=50 rows=3]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged||no safety concerns at this time||safety concerns d/t depressed agitated mood|safety concerns d/t impulsiveness|safety concerns d/t hostile temper|safety concerns d/t past attempts|safety concerns d/t current suicidal verbalization|"][textarea cols=50 rows=3]

DISPOSITION: [checkbox name="disposition" value="home||advised to use UC for acute non-emergent problems|ER for immediate treatment via 911|ER for immediate treatment via private transport||declined emergency transfer||left exam room before visit conclusion|was asked to leave clinic|"][textarea cols=50 rows=3]
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, [checkbox name="next" value="here|in-person|televisit||24 hours|2-3 days|1-2 weeks|3 weeks||30 days|6 weeks|2-3 months|4-5 months|6 months|12 months||f/u acute episode|f/u labs|f/u imaging|f/u med change/new|"][textarea cols=50 rows=3]

BARRIERS TO CARE: [checkbox name="barriers" value="language barrier|socio-cultural factors||poor effort/cooperation with exam|incomplete history|history not supported by findings|vague complaints||supporting documentation unavailable|failed to obtain old records|failed to complete referrals or testing|| multiple comorbidities|polypharmacy|multiple providers/prescribers|intolerance of/allergty to/therapeutic failure on multiple meds||frequent ER/UC visits|frequent office contacts||poor compliance with POC|negative attitude to proposed tx|lack of interest in non-drug tx||overreliance on short-acting meds|overwhelming focus on Rx drugs||poor insight|lack of motivation|dependent attitude||preoccupation with illness|unhealthy coping mechanisms|somatization|catastrophization|pessimism|overgeneralization|unrealistic health beliefs||psych comorbidity|anxiety|depression|alcohol or substance use||social or occupational dysfunction|secondary gain||hostile/disruptive behavior|affect||none noted at this time|"][textarea cols=50 rows=1]

TOTAL F2F TIME:
[checkbox name="time" value="15 minutes or less|15-30 minutes|30-45 minutes|visit dominated by counseling"]

Elias Lu, APRN


CC:

HPI/SYMPTOMS:

MEDICATIONS: allergies reviewed,


REVIEW OF SYSTEMS: negative except as stated in HPI
General:
HEENT:
CV:
Pulmonary:
GI:
GU:
MSK:
Neurologic:
Psychiatric:
Dermatologic:
Endocrine:
Hematologic/lymphatic:

-------------------------------------

OFFICE DIAGNOSTICS:
Appearance:
Skin:
Head/Face:
Eyes:
Ears:
Nose:
Mouth:
Throat:
Neck:
Chest:
Abdomen:
GU:
MSK:
Neuro:
Speech/Vocalization:
Behavior/Psychomotor Activity:


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



Discussion:


REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services,
DISCHARGE CONDITION/SAFETY:

DISPOSITION:
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx,

BARRIERS TO CARE:

TOTAL F2F TIME:


Elias Lu, APRN

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