Allergic Rhinitous/Chronic Rhinitous/Cough/Dyspnea/URI
HPI: [comment memo="URI/URTI Upper Respiratory Tract Infection HPI Template"] [text size="4"]yo [select value="M|F"] with [comment memo="symptoms"][checkbox name="URTIsx" value="runny nose|stuffy nose|itchy eyes|watery eyes|ear pain|sinus pain in cheeks and/or forehead|sore throat|pain with swallowing|difficulty swallowing|hoarseness|productive cough|dry cough|fever|chills|body aches"] for the past [text size="4"] [select value="day(s)|week(s)"][comment memo="duration"] [conditional field="URTIsx" condition="(URTIsx).is('ear pain')||(URTIsx).is('sinus pain in cheeks and/or forehead')||(URTIsx).is('sore throat')||(URTIsx).is('pain with swallowing')"]-Pain severity: [text size="4"]/10 [/conditional]-Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria"][conditional field="Centor" condition="(Centor).is('YES')"] Modified Centor Score [select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F [select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing [select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes [select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates [select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional] [comment memo="modifying factors"] -Therapies tried that have improved symptoms: [text size="50"] -Therapies tried that have NOT improved symptoms: [text size="50"] -[comment memo="Additional comments:"][textarea] Review of Systems: [radio value="fever"][radio value="chills"][radio value="body aches"][radio value="chest pain"][radio value="nausea"][radio value="vomiting"][radio value="diarrhea"] [comment memo="For use in CRDAMC FM Clinic"] Dyspnea Onset [text] prior to evaluation Onset while [text] Now it is of [text] severity at the time of this evaluation. At it worst it is of [text] severity. The dyspnea is relieved with [text] [select value="no|YES"] <-- worse lying flat [select value="no|YES"] <-- exertional [select value="no|YES"] <-- worse with coughing [select value="no|YES"] <-- cough [text] productive of sputum [select value="no|YES"] <-- wheezing [select value="no|YES"] <-- chest pain [select value="no|YES"] <-- palpitations [select value="no|YES"] <-- fever [select value="no|YES"] <-- diaphoresis Pertinent PMH: [select value="no|YES"] <-- COPD [select value="no|YES"] <-- Asthma. [select value="no|YES"] <-- CHF [select value="no|YES"] <-- Coronary Disease [select value="no|YES"] <-- Prior Intubations Tobacco use: [text] Pertinent Medications: Albuterol recent use up to every [text] and was last used [text] Steroid inhaler: [text] Oral steroids last used: [text] Pitfalls: [select value="no|YES"] <-- Pneumothorax history or risk [select value="no|YES"] <-- Pneumonia history or risk [select value="no|YES"] <-- unilateral leg swelling [select value="no|YES"] <-- recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy [select value="no|YES"] <-- anxiety related symptoms such as panic, dizziness, or finger paresthesias. [checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"] reference: [link url="//www.fpnotebook.com" memo="#1"] Dr. Scott Moses, creator/author of the Family Practice Notebook [/conditional] [comment memo="Use with Cough symptoms Patient Questionnaire"] [text size="3"]yo [select name="Sex" value="|M|F"] with cough for [text size="4"] [select value="day(s)|hour(s)|week(s)|month(s)"] [comment memo="Initial questions"] -Cough is [select name="prod" value="non-productive|productive"][conditional field="prod" condition="(prod).is('productive')"] - sputum color is [text size="20"][/conditional] -Cough started when/while [text memo="inciting event" size="80"] -Remedies/medicines attempted: [text size="80"] -Effect of attempted remedies/medicines: [text size="80"] -Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"] -Patient describes severity is [select value="minimal|moderate|severe"] -Patient feels cough at nighttime [select value="not significantly affecting sleep|preventing adequate sleep"] -Patient reports [select value="no known|known"] sick contacts at home, school, or work. [text size="40"] -Other associated symptoms: --[select value="no|YES"] <-chest pain with coughing --[select value="no|YES"] <-coughing up blood --[select value="no|YES"] <-fever/chills --[select value="no|YES"] <-body aches --[select value="no|YES"] <-hoarseness --[select value="no|YES"] <-sore throat --[select value="no|YES"] <-runny/stuffy nose --[select value="no|YES"] <-ear pain --[select value="no|YES"] <-sinus pain --[select value="no|YES"] <-itchy/watery eyes --[select value="no|YES"] <-pain with swallowing --[select value="no|YES"] <-feeling of lump in throat (globus sensation) -Hx of these conditions: --[select value="no|YES"] <-recent cold --[select value="no|YES"] <-allergic rhinitis --[select value="no|YES"] <-non-allergic rhinitis --[select value="no|YES"] <-frequent sinus infection --[select value="no|YES"] <-asthma --[select value="no|YES"] <-frequent pneumonia --[select value="no|YES"] <-frequent bronchitis --[select value="no|YES"] <-GERD --[select value="no|YES"] <-head/neck/throat/thyroid/lung cancer --[select value="no|YES"] <-tuberculosis or positive tuberculin skin test --[select value="no|YES"] <-Diabetes Mellitus Tobacco: [checkbox name="tobacco" value="never smoked/chewed/dipped/vaped tobacco/nicotine products|currently smokes/chews/dips/vapes tobacco/nicotine products|formerly smoked/chewed/dipped/vaped tobacco/nicotine products|regularly exposed to second-hand smoke"][conditional field="tobacco" condition="(tobacco).is('currently smokes/chews/dips/vapes tobacco/nicotine products')||(tobacco).is('formerly smoked/chewed/dipped/vaped tobacco/nicotine products')"] [text memo="#packs per day & #years & how long ago quit if applicable" size="20"][/conditional]. Travel: recent travel in past 6 months to foreign country and regular close contact with local people where tuberculosis is endemic- [select value="no|YES"] [text size="50"] Immunizations: [select value="vaccines UTD per CDC schedule including pertussis|PERTUSSIS VACCINATION STATUS UNKNOWN|UNVACCINATED TO PERTUSSIS"] [conditional field="Sex" condition="(Sex).is('F')"] -Currently pregnant- [select name="pg" value="|no|unsure|YES"][/conditional][conditional field="pg" condition="(pg).is('no')||(pg).is('unsure')"] -Current contraception method: [text size="40"] -LMP: [text size="10"][/conditional] [textarea memo="add'l comments"] [comment memo="For use in CRDAMC FM Clinic"] [select value="less than 1 day|1 day|2 days|3 days|4 days|5 days|6 days|7 days|more than 1 week|more than 1 month"] <-- duration [select value="no|YES"] <-- nasal congestion [select value="no|YES"] <-- nasal discharge [select value="no|YES"] <-- sneezing [select value="no|YES"] <-- watery eyes [select value="no|YES"] <-- cough [select value="no|YES"] <-- headache [select value="no|YES"] <-- fever [select value="no|YES"] <-- past history of similar symptoms Allergies identified [select value="no|YES"] <-- ragweed [select value="no|YES"] <-- tree pollen [select value="no|YES"] <-- mold [select value="no|YES"] <-- grass [select value="no|YES"] <-- animal dander Prior treatment [select value="no|YES"] <-- over the counter antihistamines [select value="no|YES"] <-- loratidine [select value="no|YES"] <-- fexofenadine [select value="no|YES"] <-- cetirizine [select value="no|YES"] <-- intranasal steroids Past History [select value="no|YES"] <-- asthma [select value="no|YES"] <-- eczema [textarea] [textarea name="variable_1" default="sample text"] [textarea name="variable_1" default="sample text"] [textarea name="variable_1" default="sample text"] [textarea name="variable_1" default="sample text"] -Symptoms-[checkbox value="watery runny nose|frequent sneezing|nasal blockage/stuffiness|itchy nose|Watery/red/itchy eyes|itchy throat|lump in throat (globus sensation)"] -Worst/most-bothersome symptom- [select value="watery runny nose|frequent sneezing|nasal blockage/stuffiness|itchy nose|Watery/red/itchy eyes|itchy throat|lump in throat (globus sensation)"] -Onset- [text size="3"] [select value="months|years"] ago -Frequency of symptoms- [text size="20"] -How bothersome symptoms are to patient? - [text size="3"]/7 [comment memo="Severity scale explanation: 1= None- occasional limited episode 3= Mildly bothersome- steady symptoms but easily tolerable 5= Moderately bothersome- symptoms hard to tolerate, may interfere with daily activities and/or sleep 7= Unbearably severe- symptoms are so bad, person can't function all the time" memo_size="small"] -Symptom Triggers- [select value="no|YES"]<-Pollen from trees, flowers and grasses [select value="no|YES"]<-Mold (both indoors and outdoors) [select value="no|YES"]<-Furred animals (especially cats, dogs and mice) [select value="no|YES"]<-Dust mites [select value="no|YES"]<-Specific seasons [select value="no|YES"]<-Weather/temperature changes (esp. cold temperatures) [select value="no|YES"]<-Tobacco smoke [select value="no|YES"]<-Strong fumes (ie. vehicle exhaust or chemicals) [select value="no|YES"]<-Perfumes [select value="no|YES"]<-Spicy foods (more than just mild runny nose) [select value="no|YES"]<-Other allergens: [text size="50"] -Current treatment(s)- [checkbox value="none"][checkbox memo="(ie. claritin/allegra/zyrtec)" memo_size="small" value="oral antihistamine"][checkbox memo="(ie. flonase/nasonex)" memo_size="small" value="intranasal steroids"][checkbox memo="(ie. astelin/patanase)" memo_size="small" value="intranasal antihistamine"][checkbox memo="(ie. sudaphed or phenyleprhine)" memo_size="small" value="oral decongestant"][checkbox memo="(ie. afrin/neosynephrine" memo_size="small" value="intranasal decongestant"][checkbox value="intranasal capsaicin"][checkbox value="nasal rinse kit"]. [text memo="other treatments if any" size="50"] -Prior treatment(s) [checkbox value="none"][checkbox memo="(ie. claritin/allegra/zyrtec)" memo_size="small" value="oral antihistamine"][checkbox memo="(ie. flonase/nasonex)" memo_size="small" value="intranasal steroids"][checkbox memo="(ie. astelin/patanase)" memo_size="small" value="intranasal antihistamine"][checkbox memo="(ie. sudaphed or phenyleprhine)" memo_size="small" value="oral decongestant"][checkbox memo="(ie. afrin/neosynephrine" memo_size="small" value="intranasal decongestant"][checkbox value="intranasal capsaicin"][checkbox value="nasal rinse kit"][checkbox value="surgery"]. [text memo="other treatments if any" size="50"] -Effect of these: [textarea] -Past Medical History of: [select value="no|YES"] <-- asthma [select value="no|YES"] <-- eczema -Further/other details: [textarea] [comment memo="7-point severity scale adapted from Wallace DV, Dykewicz MS, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph CC, Schuller D, Spector SL, Tilles SA. The diagnosis and management of rhinitis: An updated practice parameter. Journal of Allergy and Clinical Immunology. 2008;122(2):S1-S84." memo_size="small"] [comment memo="For use in CRDAMC FM Clinic"]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.75, 188 form elements, 541 boilerplate words, 33 text boxes, 9 text areas, 21 checkboxes, 7 radio buttons, 96 drop downs, 1 links, 13 comments, 1 calculations, 7 conditionals, 189 total clicks
Send Feedback for this SOAPnote