[checkbox name="Q1" value="ADHD|Anemia|Asthma|Back|Blood Pressure|Chest Pain|Headache|History of Presenting Illness (HPI)|Sore Throat"]
[conditional field="Q1" condition="(Q1).is('ADHD')"]
The ***teacher/parent*** endorsed a T score of *** for Oppositional, a T score of *** for Cognitive Problems/Inattention, a T score of *** for Hyperactivity, and a T score of *** for Conners' ADHD Index.
[conditional field="Q1" condition="(Q1).is('Asthma')"]
Symptoms include ***wheezing/daytime cough/nighttime cough/cough with exercise/shortness of breath/chest tightness***
*** nights per month
*** days per month
Triggers ***colds/irritants/allergies/exercise/weather changes***
In the last year: *** ER/UCC visit(s), *** hospitalization(s), *** oral steroid course(s), *** missed school day(s), *** missed parent work day(s)
Barriers to taking medications: ***side effects/refusal/social concerns***
Inhaler use: lasts approximately ***weeks***, ***does/does not*** use a spacer
Peak flow meter: range is ***
Associated symptoms: ***iitchy, red eyes/stuffy nose/sneezing/chronic sore throat/post-nasal drip/eczema/GE reflux***
Associated symptoms are ***under/not under** good control.
Exposures include ***smoke/pets/irritants/allergens***
Previous testing and evaluations include ***pulmonary function tests/subspecialist visit(s)/allergy testing***
[conditional field="Q1" condition="(Q1).is('Back')"]
S: no gait/bowel/bladder problems, no fever/weight loss/malaise, minimal benefit from OTC NSAIDS
[conditional field="Q1" condition="(Q1).is('Blood Pressure')"]
The patient is here today for a blood pressure evaluation.
- chest pain,
- shortness of breath
- new leg edema.
[conditional field="Q1" condition="(Q1).is('Chest Pain')"]
Onset prior to evaluation
Associated Pain (0=none, 10=severe)
Severity now (0-10):
Severity at worst (0-10):
Characterized as: .
The pain is relieved with
- exertional pain
- pleuritic pain
- shortness of breath
- Coronary Disease
- Cerebrovascular disease
- Diabetes Mellitus
- Peptic Ulcer or GERD
- Chest injury or overuse
- Aspirin was taken today
- unilateral leg swelling
- recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy
Cardiovascular risks are reviewed as follows:
Family history of Premature CAD or CVA (age less than 55):
[conditional field="Q1" condition="(Q1).is('Headache')"]
The patient is here today for a headache evaluation.
Patient describes the location to be *; quality is described as a *; intensity is rated a * out of 10. Symptoms have been present for * in length; frequency described as occuring every *; onset described as being *. Triggers are **not yet identified by patient. Relief occurs whenever *.
Migraine features such as:
are all absent***
Additionally, other more specific features such as
- lacrimation congestion
- nasal congestion
- continuous symptoms over weeks
- located over half of head
are all absent***.
Secondary causes such as an association with
- neck movement,
- scalp tenderness,
- jaw pain,
- temporal pain,
- jaw claudication,
- visual loss,
- rebound headaches from analgesia
are all absent***.
Red flags such as
- weight loss,
- focal deficits,
- decreased level of conciousness,
- field defects,
- sudden onset,
- "thunderclap like",
- associated with activity/positional changes
- first headache in patient >50 or with cognitive change
- change from known a headache pattern
- HIV positive,
- concominant OCP + smoking,
- hematologic abnormalities
are all absent***.
[conditional field="Q1" condition="(Q1).is('History of Presenting Illness (HPI)')"]
The patient is a AGE + GENDER who presents to the the clinc complaining of CHIEF COMPLAINT that began ONSET while CONTEXT. Symptoms have been TIMING since onset and pt rates them as SEVERITY in severity. Patient reports the symptoms are located LOCATION and describes the quality as QUALITY. Symptoms associated with POSITIVE SYMPTOMS but denies any NEGATIVE SYMPTOMS.
Symptoms are improved with MODIFYING FACTOR and exacerbated by MODIFYING FACTOR. Patient REPORTS/DENIES history of similar symptoms.
Pertinent medical history includes PERTINENT PAST MEDICAL HISTORY.
Patient adds OTHER DETAILS.
[conditional field="Q1" condition="(Q1).is('Sore Throat')"]
The patient is here today for evaluation of their sore throat.
Patient describes the sore throat to be
- located *;
- quality *;
- and intensity to be rated a * out of 10.
- Symptoms have been present for * in length;
- frequency as *;
- onset as ***;
- triggers to be *;
- Relief *.
Patient denies any
- swollen lymph nodes
- Cough is not productive
- Cough is not associated with chest pain
- Cough is not associated with shortness of breath.
- Patient has been vomiting
- Appetite has been decreased
- Appetite has been increased
[conditional field="Q1" condition="(Q1).is('Anemia')"]
Step 1: Lab tests: Hemoglobin (Hb) concentration, MCV & RDW, reticulocyte count, peripheral blood smear
Step 2: Use MCV to classify the anemia -- Microcytic (MCV < 80), normocytic (MCV 80-100), macrocytic (MCV >100)
Step 3: Identify cause -- Additional tests to identify the precise cause of anemia
Step 4: Treatment -- Apply appropriate treatment and evaluate response to therapy
Determining Anemia Type
Identifying Possible Anemia Causes
↓ RBC production
Stem cell failure
Myelodysplastic syndromes or leukemia
Progenitor cell failure
Pure red cell aplasia
Anemia of renal failure
Anemia of chronic disease
Endocrine cause (hypothyroidism)
Precursor cell failure
Dietary deficiency (iron deficiency)
Enzyme deficiency (G-6-PD)
Medication/ drug (EtOH)
↑ RBC destruction
Membrane defects (hereditary spherocytosis)
Globin defects (sickle cell disease)
Enzyme defects (pyruvate kinase deficiency)
Acute blood loss
[checkbox name="Q#" value="x|x"]
[conditional field="Q#" condition="(Q#).is('x')"]
[checkbox name="Q3" value="Syncope|Dizziness"]
[conditional field="Q3" condition="(Q3).is('Syncope')"]
[conditional field="Q3" condition="(Q3).is('Dizziness')"]
[checkbox name="Q4" value="Anemia|x"]
[conditional field="Q4" condition="(Q4).is('Anemia')"]