Cough Adult

[textarea]ID: smoker,asthmatic,COPD
HPI:
O: sudden, post viral , gradual
D:acute or chronic > 8 weeks
F:
Dry/ Productive - pneumonia
Painful/painless
[/textarea]
Medications:[checkbox name="field_name" value="ACE|BB|inhalers"]
[textarea]Pertinent Negatives
COPD: non smoker, pk year,
CHF: no  SOBOE,orthopnea, PND
Viral Pharyngitis/ common cold
Strep throat/ bacterial phryngitis: pain, centor score
Asthma:  no history of atopy, not worse at night in the cold, with exercise, no wheeze, dyspnea, no puffer
Pneumonia: no fever, purulent sputum, SOB, chest pain or pleurisy,
Sinusitis: No frontal headache, maxillary or frontal sinus pressure, coryza, dental pain, fever
GERD : no heartburn or  reflux, unrelated to meals,
Foreign body: no unobserved sudden onset
PE: No hemoptysis, leg pain, or history of immobilization
Cancer: no weight loss, night sweats,[/textarea]

NO Red Flags including
SOB
Hemoptysis
Exposure to chemicals, TB, HIV
Weight loss

Medications:


NO Red Flags including
SOB
Hemoptysis
Exposure to chemicals, TB, HIV
Weight loss

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.33, 3 form elements, 14 boilerplate words, 2 text areas, 1 checkboxes, 5 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published.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

More SOAPnotes by this Author: