Consult H&P (Skin and Wound) V1.0

REFERRING PHYSICIAN:
[text name="variable_1" default=""]

REASON FOR REFERRAL: 
[text name="variable_2" default=""]

PAST MEDICAL HISTORY: 

[checkbox name="variable_1" value="Hypertension|Denies hypertension|Dyslipidemia|Denies dysplipidemia|Diabetes Mellitus type 2|Denies diabetes mellitus type 2|Diabetes mellitus type 1|Denies diabetes mellitus type 1|Peripheral Arterial Disease|Denies peripheral arterial disease| Coronary artery disease|Denies coronary artery disease|Myocardial infarction|Denies myocardial infarction|Cerebrovascular accident|Denies cerebrovascular accident|Sensory Neuropathy|Denies sensory neuropathy|Retinopathy|Denies Retinopathy|Nephropathy|Denies nephropathy|Lower Extremity Wound|Denies lower extremity wound|Congestive Heart Failure|Denies congestive heart failure|Arrhythmia|Denies arrhythmia|Liver cirrhosis|Denies liver cirrhosis|Seizure disorder|Denies seizure disorder"]
Other Historical Elements:
[textarea name="variable_1" default=""]

MEDICATIONS: 
[checkbox name="variable_2" value="Nil"]
[textarea name="variable_2" default=""]

ALLERGIES: 
[checkbox name="variable_3" value="Nil|Penicillin|1st generation cephalosporin (Cephalexin/Cefazolin)|3rd generation cephalosporin (ceftriaxone)|Sulfa|Macrolide|Vancomycin|Clindamycin|Doxycycline|Macrobid (Nitrofurantoin)|Environmental"]
When did  your last reaction occur?
[text name="variable_3" default=""]
[checkbox name="variable_4" value="Lip swelling|Denies lip swelling|Tongue swelling|Denies tongue swelling|Hives|Denies hives|Severe blistering disease|Denies severe blistering disease|Anaphylaxis|Denies anaphylaxis"]

INTOLERANCES:
[textarea name="variable_3" default=""]


SOCIAL HISTORY: 
[checkbox name="variable_5" value="Endorses Tobacco use|Denies Tobacco use|Endorses alcohol|Denies alcohol|Endorses Marijuana Use|Denies Marijuana use|Endorses Recreational drug use|Denies recreational drug use|Endorses Injection Drug use|Denies Injection Drug use|Endorses Intranasal drug use|Denies Intranasal drug use"]
[textarea name="variable_4" default=""]


OCCUPATIONAL HISTORY: [checkbox name="variable_6" value="Deferred|Retired|Disabled"]
[textarea name="variable_5" default=""]


Travel HISTORY (within the last 6-12 months): [checkbox name="variable_8" value="Deferred"]
[textarea name="variable_6" default=""]

REMOTE TRAVEL HISTORY: [checkbox name="variable_9" value="Deferred"]
[textarea name="variable_7" default=""]

OTHER EXPOSURES: [checkbox name="variable_10" value="Deferred"]
[textarea name="variable_8" default="Animals:
Chemicals:"]

SEXUAL HISTORY: [checkbox name="variable_11" value="Deferred"]
Do you currently have a sex partner(s)? 
[checkbox name="variable_12" value="Yes|No"]

Do you have sex with: 
[checkbox name="variable_13" value="Males|Females|Both"]

If yes, do you use barrier protection? 
[checkbox name="variable_14" value="Yes|No"]

Modes of sexual activity: 
[checkbox name="variable_15" value="Oral receptive|Oral insertive|Vaginal receptive|Vaginal insertive|Anal receptive|Anal insertive"]

Past Sexually Transmitted infections: [checkbox name="variable_16" value="Deferred"]
[checkbox name="variable_17" value="Denies all STIs|Chlamydia|Gonorrhea|Syphilis|Herpes simplex |Trichomonas|HPV|Bacterial vaginosis|Denies all other STIs"]

FAMILY HISTORY: [checkbox name="variable_18" value="Deferred|Non-contributory"]
[textarea name="variable_9" default=""]

HISTORY OF THE PRESENTING ILLNESS: 

What is your main concern right now? 
[textarea name="variable_10" default=""]
Have you seen any other doctors about this?
[checkbox name="variable_19" value="Yes|No"]
[textarea name="variable_11" default=""]

Onset: 
[textarea name="variable_12" default=""]
Duration: 
[textarea name="variable_13" default=""]
Quality: 
[checkbox name="variable_20" value="Sharp |Dull|Constant|Intermittent"]
Severity: 
[checkbox name="variable_21" value="Mild |Moderate|Severe|Very Severe"]
Progression (Is it worse, better, or the same?: 
[checkbox name="variable_22" value="Worsening|Improving|Remains the same"]
[textarea name="variable_14" default=""]
Aggravating factors:
[textarea name="variable_15" default=""]
Alleviating factors: 
[textarea name="variable_16" default=""]

SYSTEMS REVIEW: 

CONSTITUTIONAL: [checkbox name="variable_23" value="Deferred"]
Fevers? [checkbox name="variable_24" value="Yes|No"]
Chills? [checkbox name="variable_25" value="Yes|No"]
Rigors? [checkbox name="variable_26" value="Yes|No"]
Diaphoresis? [checkbox name="variable_27" value="Yes|No"]
     If yes, is it nocturnal?[checkbox name="variable_28" value="Yes|No"]
     If yes, is it drenching?[checkbox name="variable_29" value="Yes|No"] 
Fatigue? [checkbox name="variable_1" value="Yes|No"]
Unintentional weight loss? [checkbox name="variable_30" value="Yes|No"]
Anorexia? [checkbox name="variable_31" value="Yes|No"]

INTEGUMENTARY [checkbox name="variable_32" value="Deferred"]
Erythema? [checkbox name="variable_33" value="Yes|No"]
     If yes, describe the location: 
[text name="variable_4" default=""]
     If yes, describe the progression: 
[checkbox name="variable_34" value="Progressing|Regressing|Remaining as is"]
Rash? [checkbox name="variable_35" value="Yes|No"]
     If yes, describe the location: 
[text name="variable_5" default=""]
     If yes, describe the character: [checkbox name="variable_36" value="Macular|Papular|Pustular|Vesicular|Bullous|Psoriatic|Eczematous"]
Wound(s)? [checkbox name="variable_37" value="Yes|No"]
     If yes, what is the duration: 
[text name="variable_6" default=""]
     If yes, describe the mechanism: 
[checkbox name="variable_38" value="Ischemic|Neuropathic|Pressure|Trauma|Laceration|Surgical"]
     If yes, is there exudate? [checkbox name="variable_39" value="Yes|No"]
     If yes, describe the character: 
[checkbox name="variable_40" value="Serous|Sanguineous|Purulent|Blue|Green|Odourous"]
     If yes, describe the volume: 
[checkbox name="variable_41" value="Small|Moderate|Large"]
Odour? [checkbox name="variable_42" value="Yes|No"]
Receiving nursing-led wound care? [checkbox name="variable_43" value="Yes|No"]
     If yes, 
[checkbox name="variable_44" value="LHIN Clinic|Home care"]
     If yes, describe the dressing regimen: 
Compress/Soak: 
[text name="variable_7" default="minutes"]
Primary: 
[text name="variable_8" default=""]
Secondary: 
[text name="variable_9" default=""]
Compression: 
[text name="variable_10" default=""]
Frequency:
[text name="variable_11" default=""]

VASCULAR: [checkbox name="variable_45" value="Deferred"]
Claudication? [checkbox name="variable_46" value="Yes|No"]
Rest pain? [checkbox name="variable_47" value="Yes|No"]
Night pain? [checkbox name="variable_48" value="Yes|No"]
Colour change to skin? [checkbox name="variable_49" value="Yes|No"]
Numbness?[checkbox name="variable_50" value="Yes|No"]
Paresthesias? [checkbox name="variable_51" value="Yes|No"]
[textarea name="variable_17" default=""]

VITAL SIGNS
Temperature: 
[text name="variable_20" default="_ degrees celsius"]
Blood pressure: 
[text name="variable_21" default="/"]
Pulse:[text name="variable_1" default="_ beats per minute"]
Respiratory rate: 
[text name="variable_22" default="_ breaths per minute"]
Oxygen saturation: 
[text name="variable_23" default="_% on ambient air/_ Litres per minute"]

PHYSICAL EXAMINATION
General: Aware, alert, oriented, and non-toxic appearing.
Cardiovascular: S1,S2, no additional heart sounds, jugular venous pulse not distended, no CIED generator/no CIED generator site tenderness, erythema, tenderness, or fluctuance.
Respiratory: Adequate air entry, clear to auscultation bilaterally, no adventitious sounds, no central cyanosis, no peripheral cyanosis, no obvious respiratory distress. 
Abdominal: Soft and non-tender, no voluntary or involuntary guarding or rigidity, no ascites by fluid wave or shifting dullness, no jaundice or icterus
Neurological: No meningeal signs, no cranial nerve deficits, no extraocular movement deficits.
Integumentary: No rash or petechiae, no wounds, or other dermal defects

Erythema? [checkbox name="variable_160" value="Yes|No"]
     If yes, describe the location: 
[text name="variable_24" default=""]
 
Rash? [checkbox name="variable_161" value="Yes|No"]

     If yes, describe the location: 
[text name="variable_25" default=""]
     If yes, describe the character: [checkbox name="variable_162" value="Macular|Papular|Pustular|Vesicular|Bullous|Psoriatic|Eczematous"]
Wound(s)? [checkbox name="variable_163" value="Yes|No"]
Number: 
[text name="variable_26" default=""]
Location:
[text name="variable_27" default=""]
Length:
[text name="variable_28" default="cm"] 
Width:
[text name="variable_29" default="cm"]
Depth: 
[text name="variable_30" default="cm"]

     If yes, describe the wound edge: 
[checkbox name="variable_164" value="Attached|Unattached|Rolled/Epibolic|Hyperkeratotic|Undermined"]
     If yes, describe the base: 
[checkbox name="variable_165" value="Granular|Hypergranular|Sloughy/Necrotic|Eschar|Not visible"]
     If yes, Describe the percentage of each: 
Granulation tissue:
[text name="variable_31" default="%"] 
Slough: 
[text name="variable_32" default="%"]
Necrotic tissue:
[text name="variable_33" default="%"]
     
If yes, is there exudate? [checkbox name="variable_166" value="Yes|No"]
     If yes, describe the character: 
[checkbox name="variable_167" value="Serous|Sanguineous|Purulent|Blue|Green|Odourous"]
     If yes, describe the volume: 
[checkbox name="variable_168" value="Small|Moderate|Large"]
     If yes, is there tunneling? [checkbox name="variable_169" value="Yes|No"]
     If yes, describe the depth:[text name="variable_34" default="cm"]
     If yes, describe the position: 
[text name="variable_35" default="O'clock"]
     If yes, describe the periwound: 
[checkbox name="variable_170" value="Macerated (MASD)|Friable|Erythematous|Edematous|Dry/flaky|Dermatitic|Serous Crust|Exfoliative"] 
Odour? [checkbox name="variable_171" value="Yes|No"]

Vascular assessment: 
[checkbox name="variable_172" value="Right dorsalis pedis pulse palpable|Left dorsalis pedis pulse palpable|Dorsalis pedis pulses palpable bilaterally|Right posterior tibial pulse palpable|Left posterior tibial pulse palpable|Posterior tibial pulses palpable bilaterally|Right Dorsalis pedis pulse audible by handheld doppler|Left dorsalis pedis pulses audible by handheld doppler|Dorsalis pedis pulses audible by handheld doppler bilaterally|Right posterior tibial pulse audible by handheld doppler|Left posterior tibial pulse audible by handheld doppler|Posterior tibial pulses audible by handheld doppler"]
Waveforms: 
[checkbox name="variable_173" value="Monophasic|Biphasic|Triphasic"]

LABORATORY DATA/IMAGING

Microbiology: 
[textarea name="variable_18" default="Peripheral blood cultures x 2 sets on :
Line cultures x 2 sets on _:
Urine culture on _: 
Sputum culture on _:
Device culture on: _"]

Hematology: 
[textarea name="variable_19" default=""]
Chemistry:
[textarea name="variable_20" default=""] 
Inflammatory markers:
[textarea name="variable_21" default=""]
Pathology: 
[textarea name="variable_22" default=""]

X-ray imaging:
[checkbox name="variable_174" value="N/A"]
[textarea name="variable_23" default=""]


CT imaging: 
[checkbox name="variable_175" value="N/A"]
[textarea name="variable_24" default="Head on _:
Soft tissues of the neck on _:
CTA Head and nekc on_:
Chest on _:
Abdomen/pelvis on _:
Lumbar spine on _: 
Thoracic spine on _:
Cervical spine on _:
CT angiogram of the lower extremities on _:"]

MRI: [checkbox name="variable_176" value="N/A"]
[textarea name="variable_25" default="Head on _: 
Lumbar spine on _:"]


Ultrasound: [checkbox name="variable_177" value="N/A"]
[textarea name="variable_26" default="Abdomen on _:"]


Echocardiogram: [checkbox name="variable_178" value="N/A|Transthoracic|Transesophageal"]
[textarea name="variable_27" default="Transthoracic on _:
Transesophageal on _:
Aortic valve: 
Mitral valve:
Tricuspid valve: 
Pulmonic valve:
Lead:"]

PROCEDURE: [checkbox name="variable_179" value="Deferred"]
Pre-procedural diagnosis: 
[text name="variable_36" default=""]
Post-procedural diagnosis: 
[text name="variable_37" default=""]
Procedure performed: 
[checkbox name="variable_180" value="Conservative sharp debridement|Debridement of open soft tissue penetrating to bone|Dermal punch biopsy|Bone biopsy"]
Start:
[text name="variable_38" default="_ am/pm"]
End:
[text name="variable_39" default="_ am/pm"]
Procedural details: The patient was advised of the risk of pain, bleeding, soft tissue injury, and the possibility of infection leading to severe complications including tissue and limb loss. The patient was also advised of the mitigating strategies. Once satisfied, the patient provided informed verbal consent to proceed. 

The area was cleansed with: 
[checkbox name="variable_181" value="10% povidone-iodine solution|2% Chlorhexidine gluconate solution|0.9% saline"]
The area was draped in the usual fashion: 
Using a:
[checkbox name="variable_182" value="Sterile, single-use 5mm dermal curette|Sterile, single-use 3mm dermal curette|#15 blade|Adson's toothed forceps|Bone rongeur"]
I was able to debride the: 
[checkbox name="variable_183" value="Non-viable tissue|Hyperkeratotic tissue|Necrotic tissue"]
In the:
[checkbox name="variable_184" value="Wound edge|Wound bed"]
This was brought down to healthy bleeding tissue. Subsequently hemostasis was achieved with: 
[checkbox name="variable_185" value="Direct pressure|Silver nitrate|Monsel's solution"]
Subsequently an antimicrobial dressing was applied. 

The procedure was tolerated well
[checkbox name="variable_186" value="Without the use of topical anaesthetic reflecting profound sensory loss|with the use of 2% lidocaine infiltrated into the wound edge and base"]
Complications:
[checkbox name="variable_187" value="Nil"] 
[textarea name="variable_28" default=""]

Estimated blood loss: 
[text name="variable_40" default="_CCs"].

ANALYSIS/PLAN 
[textarea name="variable_29" default="1.
2.
3.
4.
5.

Wound Dressings: 
Compress/Soak: 
Primary:
Secondary: 
Compression:
Frequency: 
"]