MMC GI Clinic Note v5

[comment memo="***SUBJECTIVE:***" memo_color="red" memo_style="bold" memo_size="large"]
***SUBJECTIVE:***
VISIT TYPE: [checkbox name="variable_110691" value="New patient|Follow-up visit"]
REASON FOR VISIT/CHIEF COMPLAINT: [select name="variable_7000" value="Anemia|Suspected UGIB|Suspected LGIB|PEG evaluation|Dysphagia|Odynophagia|Esophageal foreign body|Esophageal food impaction|Abnormal LFTs|Abdominal pain|Gastric volvulus|Cecal volvulus|Sigmoid volvulus|Hepatic steatosis|New cirrhosis|Compensated cirrhosis|Decompensated cirrhosis|Suspected choledocholithiasis|Acute cholangitis|Acute cholecystitis|Abnormal imaging findings|Screening colonoscopy|Surveillance colonoscopy|Other"] [textarea name="variable_49621" default=""]

HISTORY OF PRESENT ILLNESS:
[textarea name="variable_3" default="The patient is a __ y/o MALE/FEMALE w/ PMHx as listed below who presents ..."]

[checkbox name="602934230948" value="upon referral of their PCP for screening colonoscopy.|The patient reports that they feel well today. They denied any acute complaints."]

[checkbox value="Denies dysphagia, odynophagia, nausea, vomiting, coffee-ground emesis, hematemesis, abdominal pain, diarrhea, constipation, melena, hematochezia, and unintentional weight loss."]

[checkbox value="REVIEW OF SYSTEMS:"]
[checkbox name="Problem601" value="General:"] [conditional field="Problem601" condition="(Problem601).is('General:')"] [checkbox value="endorses fever/chills|denies fever/chills|endorses fatigue|denies fatigue|endorses malaise|denies malaise|endorses weight loss|denies weight loss|endorses weight gain|denies weight gain"] [textarea name="gen" default=""][/conditional]
[checkbox name="Problem602" value="HEENT:"] [conditional field="Problem602" condition="(Problem602).is('HEENT:')"] [checkbox value="endorses headaches|denies headaches|endorses vision changes|denies vision changes|endorses rhinorrhea|denies rhinorrhea|endorses sore throat|denies sore throat"] [textarea name="heent" default=""][/conditional]
[checkbox name="Problem603" value="Cardiac:"] [conditional field="Problem603" condition="(Problem603).is('Cardiac:')"] [checkbox value="endorses chest pain|denies chest pain|endorses palpitations|denies palpitations|endorses peripheral edema|denies peripheral edema"] [textarea name="cardiac" default=""][/conditional]
[checkbox name="Problem604" value="Pulmonary:"] [conditional field="Problem604" condition="(Problem604).is('Pulmonary:')"] [checkbox value="endorses shortness of breath at rest|denies shortness of breath at rest|endorses dyspnea on exertion|denies dyspnea on exertion|endorses cough|denies cough|endorses sputum production|denies sputum production"] [textarea name="pulm" default=""][/conditional]
[checkbox name="Problem605" value="GI:"] [conditional field="Problem605" condition="(Problem605).is('GI:')"] [checkbox value="endorses dysphagia|denies dysphagia|endorses odynophagia|denies odynophagia|endorses nausea|denies nausea|endorses vomiting|denies vomiting|endorses coffee-ground emesis|denies coffee-ground emesis|endorses hematemesis|denies hematemesis|endorses abdominal pain|denies abdominal pain|endorses diarrhea|denies diarrhea|endorses constipation|denies constipation|endorses melena|denies melena|endorses hematochezia|denies hematochezia"] [textarea name="gen" default=""][/conditional]
[checkbox name="Problem606" value="GU:"] [conditional field="Problem606" condition="(Problem606).is('GU:')"] [checkbox value="endorses suprapubic pain|denies suprapubic pain|endorses dysuria|denies dysuria|endorses nocturia|denies nocturia|endorses hematuria|denies hematuria"] [textarea name="gen" default=""][/conditional]
[checkbox name="Problem607" value="Neurologic:"] [conditional field="Problem607" condition="(Problem607).is('Neurologic:')"] [checkbox value="endorses headaches|denies headaches|endorses dizziness|denies dizziness|endorses loss of consciousness|denies loss of consciousness|endorses seizures|denies seizures|endorses numbness|denies numbness|endorses weakness|denies weakness|endorses balance problems|denies balance problems"] [textarea name="neuro" default=""][/conditional]
[checkbox name="Problem608" value="MSK:"] [conditional field="Problem608" condition="(Problem608).is('MSK:')"] [checkbox value="endorses myalgias|denies myalgias|endorses arthalgias|denies arthalgias|endorses joint swelling|denies joint swelling|endorses back pain|denies back pain"] [textarea name="msk" default=""][/conditional]
[checkbox name="Problem609" value="Dermatologic:"] [conditional field="Problem609" condition="(Problem609).is('Dermatologic:')"] [checkbox value="endorses pruritus|denies pruritus|endorses rashes|denies rashes|endorses sores|denies sores"] [textarea name="derm" default=""][/conditional]
[checkbox name="Problem610" value="Hematologic/Oncologic:"] [conditional field="Problem610" condition="(Problem610).is('Hematologic/Oncologic:')"] [checkbox value="endorses abnormal bleeding|denies abnormal bleeding|endorses abnormal bruising|denies abnormal bruising|endorses abnormal growths|denies abnormal growths"] [textarea name="hemeonc" default=""][/conditional]
[checkbox name="Problem611" value="Endocrine:"] [conditional field="Problem611" condition="(Problem611).is('Endocrine:')"] [checkbox value="endorses polyuria|denies polyuria|endorses polydipsia|denies polydipsia|endorses polyphagia|denies polyphagia"] [textarea name="endo" default=""][/conditional]

PAST MEDICAL & SURGICAL HISTORY:
[checkbox value="Dementia|Nonverbal, bedbound, trach to vent, PEG|Nonverbal|Bebound|Trach to vent|PEG|CVA|CAD|CAD s/p PCI|CAD s/p CABG|CAD s/p PCI & CABG|HFpEF|HFmrEF|HFrEF|Atrial fibrillation|T2DM|HTN|HLD|CKD|ESRD|on HD M/W/F|on HD Tu/Th/Sat|Asthma|COPD|ILD|on home O2|Hypothyroidism|Hyperthyroidism|GERD|PUD|Hx of Hepatitis B|Hx of Hepatitis C|Hx of Hepatitis B & C|Compensated liver cirrhosis|Decompensated liver cirrhosis|Seizure disorder|HIV|HIV/AIDS|Alcohol use disorder|Substance use disorder(s)|Psychiatric disorder(s)"]
[textarea name="variable_5" default=""]

PAST ENDOSCOPIC HISTORY + HISTOPATHOLOGY:
[checkbox value="None|Denies|None @ MMC|Prior endoscopy/endoscopies @ MMC; see SCM for full procedure report(s)|Prior endoscopy/endoscopies @ outside facility|Records of full procedure report(s) will have to be obtained|Unknown|Non-contributory"]
[textarea name="variable_7" default=""]

ALLERGIES (MEDICATION*(S)/ENVIRONMENTAL/FOOD):
[checkbox value="NKDA|Penicillin|Contrast|Shellfish|Sulfonamides|Unknown"]
[textarea name="variable_8" default=""]

OUTPATIENT MEDICATIONS:
[checkbox value="No NSAIDs|No anticoagulation|No antiplatelet agents|No NSAIDs/anticoagulation/antiplatelet agents|On Aspirin|On Aspirin & Plavix|On Plavix|On Eliquis|On Xarelto"]
[textarea name="variable_11069102" default=""]

SOCIAL HISTORY:
[checkbox value="Denies ACTIVE tobacco, alcohol, or illicit drug use"]
[checkbox name="Problem800" value=""] [conditional field="Problem800" condition="(Problem800).is('')"] [textarea name="tob" default="Tobacco: <br>Alcohol: <br>Illicit drugs: "][/conditional]

FAMILY HISTORY:
[checkbox value="No known history of gastrointestinal/hepatobiliary malignancies in 1st degree relatives|No known history of gastrointestinal malignancies in 1st degree relatives|No known history of hepatobiliary malignancies in 1st degree relatives|Unknown|Non-contributory"]
[textarea name="variable_2625151" default=""]

[comment memo="***OBJECTIVE:***" memo_color="red" memo_style="bold" memo_size="large"]
***OBJECTIVE:***
VITAL SIGNS:
[checkbox value="Reviewed/See in relevant section."]
[checkbox name="Problem11069104" value=""] [conditional field="Problem11069104" condition="(Problem11069104).is('')"]  [textarea name="gen" default="Temperature - <br>Heart rate - <br>Respiratory rate - <br>Oxygen saturation - <br>Blood pressure - "][/conditional]

[checkbox value="PHYSICAL EXAMINATION:"]
[checkbox name="Problem500" value="GENERAL:"] [conditional field="Problem500" condition="(Problem500).is('GENERAL:')"] [checkbox value="pediatric|adult|elderly|male|female|laying in bed|sitting up in bed|sitting up in chair|sitting up in chair at bedside|walking around in room|well-groomed|disheveled|cachectic|thin-appearing|normal weight|overweight|obese|morbidly obese|well-appearing|acutely-ill appearing|chronically-ill appearing|appears comfortable|appears uncomfortable|appears in pain|in no acute distress|in mild distress|in moderate distress|in severe distress|toxic in appearance"] [textarea name="gen" default=""][/conditional]
[checkbox name="Problem502" value="HEENT:"] [conditional field="Problem502" condition="(Problem502).is('HEENT:')"] [checkbox value="normocephalic|atraumatic|PERRL|PERRLA|EOMI|anicteric sclera|scleral icterus|mmm|neck supple|no cervical LAD|+cervical LAD|thyroid non-enlarged/non-tender|trachea midline|no JVD|+JVD"] [textarea name="heent" default=""][/conditional]
[checkbox name="Problem503" value="HEART:"] [conditional field="Problem503" condition="(Problem503).is('HEART:')"] [checkbox value="regular rate/rhythm|irregularly irregular rhythm|bradycardic|tachycardic|+s1|+s2|+s3|+s4|no murmurs|no clicks|no rubs|no gallops|no peripheral edema b/l|+1 peripheral edema b/l|+2 peripheral edema b/l"] [textarea name="heart" default=""][/conditional]
[checkbox name="Problem504" value="LUNGS:"] [conditional field="Problem504" condition="(Problem504).is('LUNGS:')"] [checkbox value="+breath sounds b/l|clear to auscultation b/l|no wheezing|+wheezing|no rales|+rales|no rhonchi|+rhonchi|decreased breath sounds b/l|decreased breath sounds on the right|decreased breath sounds on the left|diminished breath sounds at lung bases|normal respiratory rate|tachypnea|bradypnea|intubated and mechanically ventilated|tracheostomy in place|on room air| on supplemental O2 via nasal canula| on supplemental O2 via NRB|on supplemental O2 via Venturi mask|on HFNC|on CPAP|on BiPAP|does not appear to be in respiratory distress|appears to be in respiratory distress"] [textarea name="lungs" default=""][/conditional]
[checkbox name="Problem505" value="ABDOMEN:"] [conditional field="Problem505" condition="(Problem505).is('ABDOMEN:')"] [checkbox value="soft|rigid abdomen|guarding|non-tender|epigastric tenderness|periumbilical tenderness|RUQ tenderness|RLQ tenderness|LUQ tenderness|LLQ tenderness|diffuse abdominal tenderness|rebound tenderness|suprapubic tenderness|right CVA tenderness|left CVA tenderness|b/l CVA tenderness|non-distended|mildly distended|moderately distended|severely distended|+bowel sounds|normal bowel sounds|absent bowel sounds|hypoactive bowel sounds|hyperactive bowel sounds|hepatomegaly|splenomegaly"] [textarea name="abd" default=""][/conditional]
[checkbox name="Problem506" value="RECTAL:"] [conditional field="Problem506" condition="(Problem506).is('RECTAL:')"] [checkbox value="no stool|brown stool|melenic stool|bright red blood|hypotonic sphincter|normal sphincter tone|hypertonic sphincter|no palpable internal hemorrhoids|palpable internal hemorrhoids|no external hemorrhoids|+external hemorrhoids|no palpable rectal masses|palpable rectal mass"] [textarea name="rect" default=""][/conditional]
[checkbox name="Problem501" value="NEURO:"] [conditional field="Problem501" condition="(Problem501).is('NEURO:')"] [checkbox value="patient is sedated|awake/alert/oriented x3|awake/alert/oriented x2|awake/alert/oriented x1|awake/alert/oriented x0|normal examination of CN 2-12|no focal deficits discernible on observation|sensation to pain, touch, proprioception normal|DTRs normal in upper/lower extremities b/l|no pathologic reflexes identified|observable right-sided deficits|observable left-sided deficits|observable b/l deficits|appears confused|obtunded|somnolent/lethargic|slurred speech|incoherent speech|mild asterixis/tremir|obvious asterixis"]. [textarea name="neuro" default=""][/conditional]
[checkbox name="Problem507" value="MSK/Extremities:"] [conditional field="Problem507" condition="(Problem507).is('MSK/Extremities:')"] [checkbox value="no edema to b/l LEs|+1 edema to b/l LEs|+2 edema to b/l LEs|no clubbing|+clubbing|no cyanosis|+cyanosis|peripheral pulses intact|weak peripheral pulses|no peripheral pulses"]. [textarea name="mskext" default=""][/conditional]
[checkbox name="Problem508" value="SKIN:"] [conditional field="Problem508" condition="(Problem508).is('SKIN:')"] [checkbox value="warm|cool|cold|dry|diaphoretic|intact|color appropriate for ethnicity|jaundiced|generalized pallor"] [textarea name="skin" default=""][/conditional]
[checkbox name="Problem409" value="PSYCH:"] [conditional field="Problem409" condition="(Problem409).is('PSYCH:')"] [checkbox value="normal mood|normal affect|flat affect|anxious appearing|tearful|agitated|verbally combative|physically combative"]. [textarea name="psych" default=""][/conditional]

[comment memo="Use if physical exam is normal"]
[checkbox name="Problem4999" value="PHYSICAL EXAMINATION:"] [conditional field="Problem4999" condition="(Problem4999).is('PHYSICAL EXAMINATION:')"] 
GENERAL: adult patient, sitting up in chair, in no acute distress
HEENT: normocephalic, atraumatic, PERRL, EOMI
CV: RRR, +s1/s2
RESP: +breath sounds b/l
ABD: soft, non-tender, non-distended, +bowel sounds
EXTREMITIES: no peripheral edema, no clubbing, no cyanosis
NEURO: no focal deficits discernible on observation
PSYCH: normal mood and affect
 [/conditional]

LABORATORY VALUES:
[checkbox value="Reviewed|Unavailable|None available for review|None recent"]
[textarea name="variable_11069101" default=""]

RADIOLOGY:
[checkbox value="No abdominal imaging|Unavailable|None available for review|None recent|CXR|Abd XR:|RUQ U/S:|CT abd/pelvis w/ IV contrast:|CT abd/pelvis w/ PO contrast:|CT abd/pelvis w/ PO/IV contrast:|CT abd/pelvis noncontrast:|CTA abdomen/pelvis w/ & w/o IV contrast:|MRCP/MRI abd w/ & w/o IV contrast:|MRI abd w/ & w/o IV contrast:|Reviewed"]
[textarea name="variable_14" default=""]

[comment memo="***ASSESSMENT:***" memo_color="red" memo_style="bold" memo_size="large"]
***ASSESSMENT:***
[textarea name="variable_15" default=""]

[comment memo="***PLAN/RECOMMENDATIONS:***" memo_color="red" memo_style="bold" memo_size="large"]
***PLAN/RECOMMENDATIONS:***
[textarea name="variable_16" default=""]

The case [select name="variable_1000" value="was discussed|is to be discussed"] w/ the [select name="variable_1001" value="clinic|on-call|consult"] attending, Dr. [select name="variable_1002" value="Elliot Fuhrer, MD|Seth Lapin, DO|Aaron Tokayer, MD|Dmitriy Khodorskiy, MD|Ira Mayer, MD|James Park, MD|Linda Lee, MD|Manol Jovani, MD|Michael Kantrowitz, DO|Negar Niknam, MD|Yuriy Tsirlin, MD|Hatef Massoumi, MD|Arun Swaminath, MD|Cindy Law, MD"].

[select name="variable_1003" value="Tanuj Chokshi, DO|Samantha Ehrlich, MD|Sadat Iqbal, MD|Steve Obanor, MD|Kaveh Zivari, MD|Larisa Garkusha, MD|Neha Sharma, MD|Diana Cheung, DO"]
Gastroenterology & Hepatology Fellow
p[text name="variable_2625152" default="6315"]

[comment memo="USEFUL LINKS:" memo_color="green" memo_style="bold" memo_size="large"]
[link url="https://openai.com/chatgpt" memo="ChatGPT 3.5"]
[link url="https://www.mdcalc.com/calc/10437/model-end-stage-liver-disease-meld" memo="MELD 3.0 Score"]
[link url="https://www.mdcalc.com/calc/340/child-pugh-score-cirrhosis-mortality" memo="Child Pugh Score"]
[link url="https://www.mdcalc.com/calc/56/maddreys-discriminant-function-alcoholic-hepatitis" memo="Maddrey's Discriminant Function"]
[link url="https://www.vocalpennscore.com/" memo="VOCAL-Penn Score"]
[link url="https://www.mayoclinic.org/medical-professionals/transplant-medicine/calculators/post-operative-mortality-risk-in-patients-with-cirrhosis/itt-20434721" memo="Mayo Score - Cirrhotic Post-Op Mortality Risk"]



***SUBJECTIVE:***
***SUBJECTIVE:***
VISIT TYPE:
REASON FOR VISIT/CHIEF COMPLAINT:


HISTORY OF PRESENT ILLNESS:



















PAST MEDICAL & SURGICAL HISTORY:



PAST ENDOSCOPIC HISTORY + HISTOPATHOLOGY:



ALLERGIES (MEDICATION*(S)/ENVIRONMENTAL/FOOD):



OUTPATIENT MEDICATIONS:



SOCIAL HISTORY:



FAMILY HISTORY:



***OBJECTIVE:***
***OBJECTIVE:***
VITAL SIGNS:















Use if physical exam is normal


LABORATORY VALUES:



RADIOLOGY:



***ASSESSMENT:***
***ASSESSMENT:***


***PLAN/RECOMMENDATIONS:***
***PLAN/RECOMMENDATIONS:***


The case w/ the attending, Dr. .


Gastroenterology & Hepatology Fellow
p

USEFUL LINKS:
ChatGPT 3.5
MELD 3.0 Score
Child Pugh Score
Maddrey's Discriminant Function
VOCAL-Penn Score
Mayo Score - Cirrhotic Post-Op Mortality Risk



Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.65, 135 form elements, 50 boilerplate words, 1 text boxes, 34 text areas, 59 checkboxes, 5 drop downs, 6 links, 6 comments, 24 conditionals, 435 total clicks
Questions/General site feedback · Help Ticket

One response to “MMC GI Clinic Note v5”

  1. Naszyjnik Rak says:

    This article is a testament to your expertise and commitment to quality content. Well done!

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: