Allen Follow up SOAP

[date name="variable_1" default=""]
IM Note.
MS2, for Dr. 
[select name="variable_2" value="Shah|Phifer"], senior: Celine Yeh and intern: Matt Ehrlich.

[comment memo="ONE-LINER"]
Patient is a [text size="3"]-year-old [select value="male|female"] with a PMH significant for [textarea name="hpi" default=""] who presented with [text name="time" default=""]   
[select value="day(s)|week(s)|month(s)"] of [textarea name="CC" default=""] most concerning for 
[textarea name="ddx" default=""]. 
 
[comment memo="SUBJECTIVE"]
Events: 
[checkbox name="No event" value="N:
No events in the last 24h to report."]

[checkbox name="Problem810" value="Y:"] [conditional field="Problem810" condition="(Problem810).is('Y:')"][textarea name="evt" default=""][/conditional]

[checkbox name="Problem801" value="Consult:"] [conditional field="Problem801" condition="(Problem801).is('Consult:')"][textarea name="consult" default=""][/conditional]

[checkbox name="Problem802" value="PT/OT:"] [conditional field="Problem802" condition="(Problem802).is('PT/OT:')"][textarea name="pt/ot" default=""][/conditional]

[checkbox name="Problem803" value="Dialysis:"] [conditional field="Problem803" condition="(Problem803).is('Dialysis:')"][textarea name="dialysis" default=""][/conditional]

This morning, the patient stated that "[textarea name="variable_113" default=""] 

[text name="variable_115" default="No events were reported overnight."]

[comment memo="OBJECTIVE"]
* Vital Signs: TEMP: [text name="variable_7" default=""] HR: [text name="variable_8" default=""] RR: [text name="variable_9" default=""] SPO2: [text name="variable_10" default=""] on [text name="variable_11" default=""] BP: [text name="variable_12" default=""]

Last bowel movement: [text name="bm" default=""]
[checkbox name="No I/Os to report" value="No I/Os to report:"]

[checkbox name="Problem804" value="I/Os:"] [conditional field="Problem804" condition="(Problem804).is('I/Os:')"][text name="i/os" default=""]/[text name="i/os2" default=""] source:[textarea name="dialysis" default=""][/conditional]

* Physical exam: [select name="variable_4" value="unchanged since yesterday|notable for new"][text name="variable_15" default=""]
* General Appearance: [select name="variable_109" value="NAD|Mildly distressed|Moderately distressed|Severely distressed|"], AOx[select name="variable_4" value="1|2|3"]
[select name="variable_13" value="well developed/well-nourished|underdeveloped/under-nourished|cachectic|"], [select name="variable_14" value="lying comfortably in bed|sitting comfortably on bed|sitting comfortably on chair|hunched over|"] [text name="variable_15" default=""]

* Heart: [select name="variable_52" value="Normal rate and rhythm|Tachycardiac|Bradycardiac|Small, weak pulse|Large bounding pulse|Bisferiens pulse|Pulsus alternans|Bigeminal pulse|Pulsus paradoxicus|"], [select name="variable_53" value="normal S1, S2|wide splitting|fixed splitting|paradoxical splitting|3rd heart sound|4th heart sound|"], [select name="variable_54" value="no murmurs, rubs, or gallops|early systolic murmur present|mid systolic (ejection) murmur present|late systolic murmur present|pan systolic murmur present|early diastolic murmur present|late diastolic mumrmur present|presystolic murmur present|continuous murmur present|pericardial rub present|gallop present|"] [text name="variable_110" default=""]
* Lungs: [select name="variable_111" value="Clear to auscultation (normal vesicular breath sounds),|Bronchial breath sounds|Diminished breath sounds|Could not auscultate|"] [select name="variable_112" value="on bilateral|on right|on left|"] [select name="variable_55" value="lung fields,|upper lung field,|lower lung field,|"] [select name="variable_56" value="no wheezing|with wheezing|with stridor|"][select name="variable_57" value=", no crackles|, with crackles|"] [select name="variable_58" value="|on left|on right|on bilateral"] [select name="variable_59" value="|upper lung field|lower lung field|lung fields"] [text name="variable_60" default=""]

[checkbox name="Problem805" value="Pertinent Positives:"] [conditional field="Problem805" condition="(Problem805).is('Pertinent Positives:')"][textarea name="pp" default=""][/conditional]

[checkbox name="Problem806" value="Pertinent Negatives:"] [conditional field="Problem806" condition="(Problem806).is('Pertinent Negatives:')"][textarea name="pn" default=""][/conditional]

[checkbox name="Problem807" value="Lines:"] [conditional field="Problem807" condition="(Problem807).is('Lines:')"][textarea name="lines" default=""][/conditional]
[checkbox name="Problem808" value="PEG:"] [conditional field="Problem808" condition="(Problem808).is('PEG:')"][textarea name="peg" default=""][/conditional]
[checkbox name="Problem809" value="Trach:"] [conditional field="Problem809" condition="(Problem809).is('Trach:')"][textarea name="trach" default=""][/conditional]


* Head: [select name="variable_16" value="Normocephalic, atraumatic|"][select name="variable_17" value=", symmetrical face|, right facial droop|, left facial droop"] [text name="variable_18" default=""]
* Eyes: [select name="variable_22" value="Bilateral|Left|Right|"] [select name="variable_23" value="normal eyelids|retracted eyelid|ptosis|palpebral swelling|"]. [select name="variable_20" value="EOMI|Dysconjugate gaze|Strabismus|Horizontal nystagmus|Vertical nystagmus|Torsional nystagmus|Mixed nystagmus|4th n. palsy|6th n. palsy|"]. [select name="variable_19" value="PERRLA|Anisocoria|Fixed pupils|Unreactive to light only|Unreactive to accommodation only|"] [select name="variable_125" value="|bilaterally|on the left|on the right"]. [select name="variable_21" value="Conjunctiva clear|Conjunctival congestion|Conjunctival chemosis|Conjunctival exudates|Conjunctival icterus|Conjunctival pallor|Subconjunctival hemorrhage|"] [text name="variable_24" default=""]
* Oral: [select name="variable_41" value="Oropharynx clear|Erythematous oropharynx|Purulent oropharynx|"], [select name="variable_42" value="moist mucosa|dry mucosa|"], [select name="variable_43" value="normal colored oral mucosa|pale oral mucosa|cyanotic oral mucosa|"] [text name="variable_44" default=""]
* Neck: [select name="variable_45" value="Supple|Stiff|Torticollis|"], [select name="variable_46" value="no cervical lymphadenopathy.|right cervical lymphadenopathy.|left cervical lymphadenopathy.|bilateral cervical lymphadenopathy.|"] [select name="variable_49" value="No tenderness|Tenderness present|"] [select name="variable_47" value="|Left|Right|Bilateral|Diffuse|Total"] [select name="variable_48" value="|thyromegaly.|thyroid nodule.|thyroid mass.|hemithyroidectomy.|thyroidectomy."] 
 [select name="variable_50" value="|Bilateral carotid bruits present|Right carotid bruit present|Left carotid bruit present"] [text name="variable_51" default=""]
* Abdomen: [select name="variable_61" value="Normal bowel sounds|Hypoactive bowel sounds|Hyperactive bowel sounds|Absent bowel sounds|Could not auscultate|"], [select name="variable_62" value="not distended|distended|"], [select name="variable_63" value="not tender|with tenderness|"] on [select name="variable_64" value="all quadrants|upper right quadrant|upper left quadrant|lower right quadrant|lower left quadrant|"], [select name="variable_67" value="no masses|with a mass|"] [select name="variable_68" value="on all quadrants|on upper right quadrant|on upper left quadrant|on lower right quadrant|on lower left quadrant|"], [select name="variable_65" value="no hepatosplenomegaly|with hepatosplenomegaly|with hepatomegaly|with splenomegaly|"] [text name="variable_69" default=""]
* Musculoskeletal: [select name="variable_70" value="Normal muscle bulk|Decreased muscle bulk (atrophy)|"], [select name="variable_71" value="moves all limbs freely|limited range of motion|"], [select name="variable_72" value="no tenderness|with tenderness|"] [select name="variable_73" value="|on right|on left|on bilateral"] [select name="variable_74" value="on all limbs|upper limb|lower limb|shoulder joint|elbow joint|wrist joint|hip joint|knee joint|ankle joint|"], [select name="variable_75" value="no swelling|with swelling|"] [select name="variable_76" value="|on right|on left|on bilateral"] [select name="variable_77" value="on all limbs|upper limb|lower limb|shoulder joint|elbow joint|wrist joint|hip joint|knee joint|ankle joint|"], [select name="variable_78" value="no masses|with a mass|"] [select name="variable_79" value="|on right|on left|on bilateral"] [select name="variable_80" value="on all limbs|upper limb|lower limb|"]. [text name="variable_81" default=""] 
* Extremities: [select name="variable_83" value="No significant deformity or joint abnormality.|With significant deformity or joint abnormality.|"] [select name="variable_84" value="No edema.|Edema +1.|Edema +2.|Edema +3.|Edema+4.|"] [text name="variable_85" default=""] [select name="variable_86" value="Peripheral pulses +3|Peripheral pulses +2|Peripheral pulses +1|Peripheral pulses +4|"]  [text name="variable_87" default=""]
* Neurological: [select name="variable_88" value="No focal neurological lesions.|Focal neurological lesion(s) present.|"] Strength: [select name="variable_121" value="5/5 on all limbs|"] [text name="variable_82" default=""][text name="variable_89" default=""] 
* Skin: [select name="variable_92" value="Normal color.|Jaundiced.|Cyanosed.|Vitiligo.|Other discoloration.|Hypopigmentation.|Hyperpigmentation.|"] [text name="variable_93" default=""] [text name="variable_93" default=""] [select name="variable_140" value="Warm|Hot|Cool|"], [select name="variable_141" value="dry|moist|"], [select name="variable_142" value="intact|non-intact"]. [text name="variable_143" default=""] [select name="variable_94" value="|Normal texture|Abnormal skin texure"] [text name="variable_95" default=""]

LABS, IMAGING, AND OTHER DIAGNOSTIC STUDIES: 
[comment memo="Labs"]
WBC most recent:[text name="wbc" default=""] range:[text name="wbc1" default=""] to [text name="wbc2" default=""]   
Hgb: most recent:[text name="hgb" default=""] range:[text name="hgb1" default=""] to [text name="hgb2" default=""] 
Hct: most recent:[text name="hct" default=""] range:[text name="hct1" default=""] to [text name="hct2" default=""] 
Plt: most recent:[text name="plt" default=""] range:[text name="plt1" default=""] to [text name="plt2" default=""] 
*BMP:
Na:[text name="na" default=""] Cl: [text name="cl" default=""]BUN: [text name="bun" default=""]
K:[text name="k" default=""] HCO3: [text name="hco" default=""]Cr: [text name="cr" default=""]

Ca: [text name="ca" default=""]
Mg: [text name="mg" default=""]
Po4: [text name="po" default=""]
GFR: [text name="gfr" default=""]
Procal: [text name="procal" default=""]
PT: [text name="pt" default=""] aPTT: [text name="aptt" default=""] INR: [text name="inr" default=""]

Additional relevant labs/trends:
[textarea name="labs" default=""] 

[comment memo="ASSESSMENT/PLAN"]
Patient is a [text size="3"]-year-old [select value="male|female"] with a PMH significant for [textarea name="hpi" default=""] on hospital day [text name="day" default=""], still admitted for [text name="reason" default=""]
[checkbox name="variable_108" value="on antibiotic"][text name="abxx" default=""][select name="variable_109" value="day 1|day 2|day 3|day 4|day 5|day 6|day 7|day 8|day 9|day 10"] [select name="variable_110" value="of 1|of 2|of 3|of 4|of 5|of 6|of 7|of 8|of 9|of 10"]


#[text name="problem1" default=""]
-[textarea name="plan" default=""]

#[text name="problem1" default=""]
-[textarea name="plan" default=""]

#[text name="problem1" default=""]
-[textarea name="plan" default=""]

#[text name="problem1" default=""]
-[textarea name="plan" default=""]

IM Note.
MS2, for Dr.
, senior: Celine Yeh and intern: Matt Ehrlich.

ONE-LINER
Patient is a -year-old with a PMH significant for who presented with
of most concerning for
.

SUBJECTIVE
Events:










This morning, the patient stated that "



OBJECTIVE
* Vital Signs: TEMP: HR: RR: SPO2: on BP:

Last bowel movement:




* Physical exam:
* General Appearance: , AOx
,

* Heart: , ,
* Lungs:










* Head:
* Eyes: . . .
* Oral: , ,
* Neck: ,

* Abdomen: , , on , ,
* Musculoskeletal: , , , , .
* Extremities:
* Neurological: Strength:
* Skin: , , .

LABS, IMAGING, AND OTHER DIAGNOSTIC STUDIES:
Labs
WBC most recent: range: to
Hgb: most recent: range: to
Hct: most recent: range: to
Plt: most recent: range: to
*BMP:
Na: Cl: BUN:
K: HCO3: Cr:

Ca:
Mg:
Po4:
GFR:
Procal:
PT: aPTT: INR:

Additional relevant labs/trends:


ASSESSMENT/PLAN
Patient is a -year-old with a PMH significant for on hospital day , still admitted for



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