The SOAPnote Project > Endocrine, Nutrition & Obesity > ros

ros

posted 2018-09-01, updated 2019-12-22

Duplicate
View
Live Form Edit Markup Data Dictionary

Constitutional/General:
 [select name="" value="c/o of|  "]  [checkbox name="1" value=" | fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]
denies [checkbox name="356" value=" | fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"]

Head:
 [select name="" value="c/o of|  "]  [checkbox name="2" value=" |headaches|dizziness|syncope|dizziness|sinus pain|LOC"]. Denies [checkbox name="43" value=" |headaches|dizziness|syncope|dizziness|sinus pain|LOC"].

Eyes:
 [select name="" value="c/o of|  "]  [checkbox name="44" value=" |vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"]. Denies [checkbox name="4" value=" |vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].

Ears: 
[select name="" value="c/o of|  "]  [checkbox name="5" value=" |ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"] Denies [checkbox name="6" value=" |ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent infections"].

Nose,Mouth, and Throat
 [select name="" value="c/o of|  "]  [checkbox name="7" value=" |loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"] Denies [checkbox name="8" value=" |loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"].
[select name="" value="c/o of|  "]  [checkbox name="9" value=" |hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"] Denies [checkbox name="10" value=" |hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"]. 

Neck: 
[select name="" value="c/o of|  "]  [checkbox name="11" value=" |neck pain|stiffness|edema"] Denies [checkbox name="13" value=" |neck pain|stiffness|edema"] 

Cardiac: 
[select name="" value="c/o of|  "]  [checkbox name="15" value=" |chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"] . Denies [checkbox name="16" value=" |chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].
[select name="" value="c/o of|  "]  [checkbox name="17" value=" |claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] . Denies [checkbox name="18" value=" |claudication|color changes in extremities|parathesias|coldness in extremities"].

Respiratory:
 [select name="" value="c/o of|  "]  [checkbox name="19" value=" |Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] . Denies [checkbox name="20" value=" |Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].

Gastrointestinal: 
[select name="" value="c/o of|  "]  [checkbox name="21" value=" |appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] . Denies[checkbox name="22" value=" |appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] 

Endocrine: 
[select name="" value="c/o of|  "]  [checkbox name="23" value=" |thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"] . Denies [checkbox name="24" value=" |thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"].

Hematological/Lymphatic: 
[select name="" value="c/o of|  "]  [checkbox name="25" value=" |anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] . Denies [checkbox name="26" value=" |anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].

Genitourinary:
 [select name="" value="c/o of|  "]  [checkbox name="27" value=" |dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"] . Denies [checkbox name="28" value=" |dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]

Reproductive (female): 
[select name="" value="c/o of|  "]  [checkbox name="29" value=" |change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"] . Denies [checkbox name="30" value=" |change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]. Gravida  Para  Abortus . LMP: .

Reproductive (male): 
[select name="" value="c/o of|  "]  [checkbox name="31" value=" |difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"] . Denies [checkbox name="32" value=" |difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"].

Musculoskeletal: 
[select name="" value="c/o of|  "]  [checkbox name="33" value=" |joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] . Denies [checkbox name="34" value=" |joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].

Integument:
[select name="" value="c/o of|  "]  [checkbox name="35" value=" |pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"] . Denies [checkbox name="36" value=" |pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"].

Neurological:
 [select name="" value="c/o of|  "]  [checkbox name="37" value=" |change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"] . Denies [checkbox name="38" value=" |change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"].

Psychiatric: 
[select name="" value="c/o of|  "]  [checkbox name="39" value=" |depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"] . Denies [checkbox name="40" value=" |depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges|irritability|tension|suicidal thoughts|homicidal thoughts"]

Breasts: 
[select name="" value="c/o of|  "]  [checkbox name="41" value=" |breast pain/soreness|discharge|lumps"]
. Denies [checkbox name="42" value=" |breast pain/soreness|discharge|lumps"]

Vital signs: T[text name="55" default="sample text"] P[text name="56" default="sample text"] R[text name="57" default="sample text"] BP[text name="58" default="sample text"] O2 Sat [text name="59" default="sample text"] on [text name="60" default="sample text"]

Nurtition: Weight: [text name="61" default="sample text"] BMI: [text name="62" default="sample text"] Weight changes: [text name="99" default="sample text"]


LABS

[textarea name="343435" default="sample text"]


Diagnosis:
[text name="633637" default="sample text"]

DDx:
[textarea name="837447" default="sample text"]
==============================================
PLAN: 
 
[textarea name="8333" default="sample text"]

Constitutional/General:
fatigue fever chills malaise generalized weakness diffuse pain sleeping problems night sweats weight changes
denies fatigue fever chills malaise generalized weakness diffuse pain sleeping problems night sweats weight changes

Head:
headaches dizziness syncope dizziness sinus pain LOC. Denies headaches dizziness syncope dizziness sinus pain LOC.

Eyes:
vision loss blurriness blind spots floaters diplopia photophobia eye pain halos erythemia drainage change in appearance dryness. Denies vision loss blurriness blind spots floaters diplopia photophobia eye pain halos erythemia drainage change in appearance dryness.

Ears:
ear pain tinnitus hearing loss fullness in ears drainage drainage vertigo frequent infections Denies ear pain tinnitus hearing loss fullness in ears drainage drainage vertigo frequent infections.

Nose,Mouth, and Throat
loss of smell obstruction epistaxis drainage congestion tenderness sinus pain lesions Denies loss of smell obstruction epistaxis drainage congestion tenderness sinus pain lesions.
hoarseness change in voice B sore throat bleeding in mouth hemoptysis swollen gums recent abscess recent extractions soreness in mouth soreness in tongue ulcers change in taste Denies hoarseness change in voice sore throat bleeding in mouth hemoptysis swollen gums recent abscess recent extractions soreness in mouth soreness in tongue ulcers change in taste.

Neck:
neck pain stiffness edema Denies neck pain stiffness edema

Cardiac:
chest pain dyspnea orthopnea edema palpitations shortness of breath with activities loss of consciousness paroxysmal nocturnal dyspnea need to elevate head at night due to SOB . Denies chest pain dyspnea orthopnea edema palpitations shortness of breath with activities loss of consciousness paroxysmal nocturnal dyspnea need to elevate head at night due to SOB.
claudication color changes in extremities parathesias coldness in extremities tendency to bruise . Denies claudication color changes in extremities parathesias coldness in extremities.

Respiratory:
Pain with Respiration Dyspnea Cyanosis Coughing Wheezing Sputum Hemoptysis Night Sweats shortness of breath exercise intolerance with activity . Denies Pain with Respiration Dyspnea Cyanosis Coughing Wheezing Sputum Hemoptysis Night Sweats shortness of breath exercise intolerance with activity.

Gastrointestinal:
appetite changes heartburn dysphagia abdominal pain nausea vomiting diarrhea constipation change in stools flatulence anorexia hematemesis intolerance to foods painful bowel movements bloating cramping anorexia bright red blood per rectum foul smelling dark black tarry stools tenesmus . Denies appetite changes heartburn dysphagia abdominal pain nausea vomiting diarrhea constipation change in stools flatulence anorexia hematemesis intolerance to foods painful bowel movements bloating cramping anorexia bright red blood per rectum foul smelling dark black tarry stools tenesmus

Endocrine:
thyroid tenderness thyroid enlargement excessive thirst excessive hunger/excessive urination heat intolerance cold intolerance unexplained Weight changes changes in face or body hair striae increased hat or glove size mood swings sweaty diarrhea oligomenorrhoea tremor, palpitations visual disturbances feeling slow feeling tired depression thin hair croaky voice heavy periods constipation dry skin orthostatic symptoms, darkening of skin in non-sun exposed places . Denies thyroid tenderness thyroid enlargement excessive thirst excessive hunger/excessive urination heat intolerance cold intolerance unexplained Weight changes changes in face or body hair striae increased hat or glove size mood swings sweaty diarrhea oligomenorrhoea tremor, palpitations visual disturbances feeling slow feeling tired depression thin hair croaky voice heavy periods constipation dry skin orthostatic symptoms, darkening of skin in non-sun exposed places.

Hematological/Lymphatic:
anemia purpura petechia prolonged or excessive bleeding after dental extraction/injury bruising blood clots enlarged lymph nodes tender lymph nodes . Denies anemia purpura petechia prolonged or excessive bleeding after dental extraction/injury bruising blood clots enlarged lymph nodes tender lymph nodes.

Genitourinary:
dysuria urinary frequency urinary urgency hematuria flank pain suprapubic pain nocturia polyuria dark or discolored Urine hesitancy terminal dribbling loss of force of stream loss or urine with laughing, coughing, sneezing, exercise, position changes loss of sensation loss of control . Denies dysuria urinary frequency urinary urgency hematuria flank pain suprapubic pain nocturia polyuria dark or discolored Urine hesitancy terminal dribbling loss of force of stream loss or urine with laughing, coughing, sneezing, exercise, position changes loss of sensation loss of control

Reproductive (female):
change in cycle duration and frequency vaginal bleeding irregularities vaginal discharge vaginal pain menstrual pain changes in sexual arousal or libido infertility painful intercourse . Denies change in cycle duration and frequency vaginal bleeding irregularities vaginal discharge vaginal pain menstrual pain changes in sexual arousal or libido infertility painful intercourse. Gravida Para Abortus . LMP: .

Reproductive (male):
difficulty with erection difficulty with sexual arousal lack of stamina difficulty with emissions testicular pain . Denies difficulty with erection difficulty with sexual arousal lack of stamina difficulty with emissions testicular pain.

Musculoskeletal:
joint pain or tenderness joint swelling muscles pain ROM changes stiffness bony deformity misalignment . Denies joint pain or tenderness joint swelling muscles pain ROM changes stiffness bony deformity misalignment.

Integument:
pruritis rashes stria lesions wounds pigmentation changes acanthosis nigricans nodules lumps/bumps excessive dryness discoloration texture changes eruptions . Denies pruritis rashes stria lesions wounds pigmentation changes acanthosis nigricans nodules lumps/bumps excessive dryness discoloration texture changes eruptions.

Neurological:
change in sight changes in smell change in hearing changes in taste change in sensation faints fits funny turns headache paraesthesias numbness paralysis limb weakness poor balance loss of coordination speech problems seizures dizziness headaches tremors memory loss . Denies change in sight changes in smell change in hearing changes in taste change in sensation faints fits funny turns headache paraesthesias numbness paralysis limb weakness poor balance loss of coordination speech problems seizures dizziness headaches tremors memory loss.

Psychiatric:
depression change in sleep patterns anxiety difficulty concentrating difficulty paying attention change in body image changes in work and school performance paranoia anhedonia lack of energy episodes of mania episodic change in personality sexual or financial binges irritability tension suicidal thoughts homicidal thoughts . Denies depression change in sleep patterns anxiety difficulty concentrating difficulty paying attention change in body image changes in work and school performance paranoia anhedonia lack of energy episodes of mania episodic change in personality sexual or financial binges irritability tension suicidal thoughts homicidal thoughts

Breasts:
breast pain/soreness discharge lumps
. Denies breast pain/soreness discharge lumps

Vital signs: T P R BP O2 Sat on

Nurtition: Weight: BMI: Weight changes:

LABS

Diagnosis:

DDx:

==============================================
PLAN:

Sandbox Metrics: Structured Data Index 0.83, 76 form elements, 69 boilerplate words, 10 text boxes, 3 text areas, 42 checkboxes, 21 drop downs, 521 total clicks

Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote Cancel reply

You must be logged in to post a comment.

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author:

ros

Result - Copy and paste this output:

Send Feedback for this SOAPnote Cancel reply