IM – Chest Pain

[checkbox name="historian" value="new patient|existing patient||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]

RECENT HISTORY:
[checkbox name="recent" value="non-contributory||visit to ER/UC|hospitalization/surgery/procedure|new medications|antibiotic use|diagnostic study|"][textarea cols=50 rows=2]

CC:
[textarea cols=50 rows=5]

Similar Sx Before:
[checkbox name="before" value="yes|no|"][textarea cols=50 rows=2]

Location:
[checkbox name="location" value="larynx|suprasternal notch|precordial|epigastric|under left breast|"][textarea cols=50 rows=1]

Onset:
[checkbox name="onset" value="days ago|hours ago||at rest|with activity|upon emotion upset|drinking coffee|using stimulants||unsure|"][textarea cols=50 rows=1]

Time Course:
[checkbox name="time" value="still present|better|worse|resolved||lasted seconds|lasted minutes|lasted hours||unsure|"][textarea cols=50 rows=1]

Quality:
[checkbox name="quality" value="pressure|tightness|dull|burning|sharp|stabbing|numbing|indigestion||unsure|"][textarea cols=50 rows=1]

Radiation:
[checkbox name="radiation" value="arm|back|neck|jaw||none|unsure|"][textarea cols=50 rows=1]

Worse with:
[checkbox name="worse" value="change in position|deep breathing|turning|exertion||unsure|"][textarea cols=50 rows=1]

Better with:
[checkbox name="better" value="change in position|sitting up|rest|antacids||unsure|"][textarea cols=50 rows=1]

ASSOCIATED SYMPTOMS: 
[checkbox name="associated" value="CP|chest pain with deep breathing|feeling of doom|SOB|cough|orthostasis|orthopnea|nocturia|PND|weight loss|weight gain|hypoglycemia|leg swelling|syncope|near-syncope|palpitations|sweating|dizziness|nausea|hand/face numbness/tingling||none reported|unsure|"][textarea cols=50 rows=1]

MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="nitrates|b-blocker||insulin||NSAID|BCP||ASA|Plavix|anticoagulants||taking as prescribed|not taking as prescribed||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages|unable to name medications/reasons/dosages||medication list/labels/containers available for review|medication list/labels/containers not available for review|"][textarea cols=50 rows=3]

AMBULATORY MONITORING:
[checkbox name="monitoring" value="insulin/BS log available for review|insulin/BS log not available for review||BP record available for review|BP record unavailable for review||reports checking BP at home|reports not checking BP at home||reports checking BS at home|reports not checking BS at home|"][textarea cols=50 rows=2]

PMH/Comorbidities:
[checkbox name="pmh" value="hypertension|LVH, CHF|CAD,MI|CVA,TIA|PAD|ED|aneurysm|atrial fibrillation|PE,DVT|COPD|BMI≥30|dyslipidemia|diabetes|retinopathy|microalbuminuria|GFR < 60|snoring,sleep apnea|cancer|recent surgery/hospitalization/procedure|GERD|anxiety|stress|"][textarea cols=50 rows=2]

PSH/CARDIAC PROCEDURES:
[checkbox name="psh" value="none reported||angio/stent|CABG|pacemaker|carotid endarterectomy|"][textarea cols=50 rows=2]

CV STUDIES:
[checkbox name="studies" value="none reported||stress test|ECHO|vascular U/S|calcium score|tilt table|"][textarea cols=50 rows=2]

PERTINENT SH:
[checkbox name="use" value="non-contributory||tobacco|cocaine|meth use|"][textarea cols=50 rows=1]



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

Constitutional:
[checklist name="constitutional_symptoms" value="fever|chills|body aches|malaise|fatigue|night sweats|hot flashes|unintentional wt loss|wt gain"][textarea cols=50 rows=2]
Head/face:
[checklist name="head_symptoms" value="headache|trauma|facial pain|facial swelling|facial drooping|facial numbness"][textarea cols=50 rows=2]
Eyes:
[checklist name="eye_symptoms" value="decrease in vision|scotoma|floaters|blurriness|photophobia|halos|dryness|redness/irritation|discharge|lid swelling|periorbital swelling|trauma|pain with EOM"][textarea cols=50 rows=2]
Ears:
[checklist name="ear_symptoms" value="pain|pressure|discharge|bleeding|wax|hearing loss|ringing"][textarea cols=50 rows=2]
Nose:
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|snoring|bleeding|trauma"][textarea cols=50 rows=2]
Mouth:
[checklist name="mouth_symptoms" value="sores|dryness|tongue pain/swelling|toothache|infection/swelling|jaw pain/clicking|changes in taste"][textarea cols=50 rows=2]
Throat:
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness|globus"][textarea cols=50 rows=2]
Neck:
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"][textarea cols=50 rows=2]
CV:
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|lightheadedness|fainting|exertional dyspnea|orthopnea|ankle swelling|ankle discoloration|varicose veins|leg cramps"][textarea cols=50 rows=2]
Chest/Respiratory:
[checklist name="chest_symptoms" value="cough|phlegm|wheezing|pain w/ breathing|rib pain|breast swelling/lump"][textarea cols=50 rows=2]
GI:
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea"][textarea cols=50 rows=2]
GU:
[checklist name="gu_symptoms" value="dysuria|burning|frequency|urgency|hematuria|hesitancy|retention|dyscharge|bleeding"][textarea cols=50 rows=2]
MSK:
[checklist name="msk_symptoms" value="myalgias|neck pain|back pain|shoulder pain|hip pain|knee pain|chronic pain/meds|joint pain/deformity|localized muscle/soft tissue pain/swelling"][textarea cols=50 rows=2]
Neuro:
[checklist name="neuro_symptoms" value="dizziness|vertigo|poor balance|abnormality of walk|focal weakness|blackouts|speech difficulty|tremor|seizures|urinary/bowel changes|tingling/numbness"][textarea cols=50 rows=2]
Psych:
[checklist name="psych_symptoms" value="irritability|confusion|withdrawal|depression|apathy|anxiety|mood swings|memory loss|insomnia"][textarea cols=50 rows=2]
Endo:
[checklist name="endo_symptoms" value="cold intolerance|skin dryness|hair loss|polyuria"][textarea cols=50 rows=2]
Lymph/Hema:
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"][textarea cols=50 rows=2]
Immune:
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"][textarea cols=50 rows=2]
Derm:
[checklist name="derm_symptoms" value="dryness|pruritus|rash|hives|redness|swelling|wounds"][textarea cols=50 rows=2]


Ambulation/DME:
[checkbox name="ambulation" value="no ambulation aids/DME|ambulation requires walker|ambulation requires cane|ambulation requires wheelchair||wearing cervical collar|wearing lumbar support|wearing extremity brace|"][textarea cols=50 rows=2]

Appearance:
[checkbox name="appearance" value="well-appearing|no signs of discomfort visible while sitting in chair|no signs of discomfort visible while ambulating & getting on/off exam table|good hygiene||normal built|heavy built|lean|well-nourished|emaciated|frail||ill-appearing|tired-looking|short of breath|diaphoretic||disheveled|bizarre clothes|body odor||drowsy|appears impaired|slumped|"][textarea cols=50 rows=2]

Skin:
[checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||tattoos|body piercings|poor turgor||dry|sweaty|"][textarea cols=50 rows=2]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|normal hair distribution|symmetrical face|CN grossly intact||plethoric face|alopecia|facial droop|"][textarea cols=50 rows=2]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear||glasses|contacts|conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 rows=2]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance|"][textarea cols=50 rows=2]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|no facial tenderness|mucosa pink & moist||swollen & boggy mucosa|mucosal congestion|clear discharge|yellow discharge|crusty discharge|rhinophyma|"][textarea cols=50 rows=2]

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|oral ulcers|gum swelling|tooth decay|"][textarea cols=50 rows=2]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates||hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal erythema w/o exudates|"][textarea cols=50 rows=2]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD|no bruit or JVD||anterior LAD|posterior LAD||thyroid enlargement|nuchal tenderness|"][textarea cols=50 rows=2]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion, no stridor|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased bilaterally|wheezing|crackles|"][textarea cols=50 rows=2]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=50 rows=2]

Abdomen:
[checkbox name="abd" value="not examined||normal visual inspection, no distension|normal active bowel sounds|soft non-tender|no abdominal bruit/pulsations||protruding|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|hypoactive bowel sounds|hyperactive bowel sounds|direct non-rebound tenderness|colostomy in situ|"][textarea cols=50 rows=2]

GU:
[checkbox name="gu" value="not examined||no suprapubic tenderness|no CVAT bilaterally||Foley in situ|normal external genitalia|no inguinal LAD||testicular tenderness|urethral discharge|verrucous papules|vesicles|crusted lesions|"][textarea cols=50 rows=2]

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||non-tender C-spine with good ROM|non-tender L-spine with good ROM||strength, tone, & bulk symmetrical & grossly intact||kyphosis|paraspinal muscle spasm|C-spine tenderness & DROM|neck pain with active motion|paracervical muscle spasm|old surgical scar(s) in C-spine|trapezius tenderness||L-spine tenderness|reduced painful ROM in lumbar region|paraspinal muscle spasm|trigger points in L-spine|old surgical scar(s) in L-spine||heel-walk & toe-walk without difficulty|negative seated SLR|positive seated SLR|"][textarea cols=50 rows=2]

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||antalgic gait|wide gait|shuffling gait||diffuse numbness w/o dermatomal pattern|dystonia|tardive dyskinesia|tics|"][textarea cols=50 rows=2]

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=2]

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=2]

OFFICE DIAGNOSTICS:
[checkbox name="office_diag" value="EKG|RBS||normal|non-specific changes|no acute findings||discussed with patient/SO|official report to follow|"][textarea cols=50 rows=3]

A/P:
[textarea cols=50 rows=7]


RX:
[checkbox name="order_RX" value="none|OTC||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=50 rows=1]

LABS: 
[checkbox name="order_lab" value="none||CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS|"][textarea cols=50 rows=2]

IMAGING:
[checkbox name="order_imaging" value="none||X-ray|US|MRI|"][textarea cols=50 rows=2]

OUTSIDE REFERRALS:
[checkbox name="order_refer" value="none|"] [textarea cols=50 rows=2]

STAFF INSTRUCTIONS:
[checkbox name="MA" value="none||dsg change/wound care as instructed|obtain hospital/ER discharge report|obtain specialty report|obtain imaging report|obtain laboratory report|remind patient to always bring all medication containers to visit|"][textarea cols=50 rows=2]

FORMS:
[checkbox name="forms" value="none|excuse|clearance|restrictions|"][textarea cols=50 rows=2]

REVIEWED/DISCUSSED:
[checkbox name="reviewed" value="MA notes|med list|medication containers|PMP|previous visits|laboratory/diagnostic studies|specialty reports|hospital discharge|"][textarea cols=50 rows=2]

INSTRUCTED ON:
exam findings, POC, risks of/benefits of/alternatives to proposed POC, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services
[checkbox name="instructions" value="alcohol cessation|smoking cessation|weight reduction/exercise|salt restriction|carbs restriction||appropriate follow up|medication compliance|bringing all medications/labels to all visits||home BP checks|home BS checks|daily weights||controlling chronic conditions|age-appropriate screening and immunization|"][textarea cols=50 rows=1]

PLAN OF CARE:
[checkbox name="discussed" value="patient/family verbalized understanding of & agreement with POC|patient/family did not agree with my POC – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=3]

PREVENTIVE:
[checkbox name="preventative" value="UTD|deferred||colonoscopy|DEXA|LDCT|PAP|mammogram|PSA|DRE||referred to local pharmacy to verify vaccination status and administer vaccines, if indicated|"][textarea cols=50 rows=2]

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=1]

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="RTC 24 hours|RTC 2-3 days|RTC 1 week|RTC 4 weeks||medication review|f/u acute episode|f/u labs|f/u imaging|f/u referral|"][textarea cols=50 rows=2]

DISPOSITION:
[checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left clinic before being discharged|asked to leave clinic|"][textarea cols=50 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none apparent at this time||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]