viral URI

CC:
[checkbox name="cc" value="headache|fever|malaise|fatigue|body aches|night sweats|runny nose|nasal congestion|PND|sinus pain|earache/ear pressure|sore throat|hoarseness|cough|chest tightness/pain w/ breathing"][textarea cols=70 rows=1]

HPI:
[checkbox name="hpi" value="sudden onset|gradual onset|started just prior to arrival|started today|started yesterday|started several days ago|started more than 1 week ago|sx increasing in severity|sx persisting|sx decreasing in severity"][textarea cols=70 rows=1]

RECENT & PAST HISTORY:     [+] reported  [-] not reported
[checklist name="recent" value="ER/UC visit|hospitalization/surgery/procedure|travel|sick contact|new/changed medications|antibiotic use|asthma/COPD|smoker|immunosuppression"]

MEDICATIONS:
allergies reviewed
[checkbox name="medications" value="taking OTC, not helping|taking ABX, not helping|not taking any medications"][textarea cols=70 rows=1]

Physical Exam:
Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB|no acute distress|malaised|short of breath|diaphoretic|coughing during exam|sniffling during exam|drowsy|appears impaired|slumped|unable to assess|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="no visible rashes|unable to assess, reports no new rashes"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic|symmetrical face|CN grossly intact|unable to assess, reports no trouble smiling or chewing"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates, anicteric sclera, EOM intact without nystagmus|conjunctival injection|epiphora|conjunctival exudate|palpebral edema|palpebral exudates|glasses|contacts|unable to assess, reports no changes in vision or photophobia"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing grossly intact|no tragal tenderness|no mastoid tenderness|tragal tenderness|HOH|hearing aid(s)|unable to assess, reports no changes in hearing"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="maxillary tenderness|frontal tenderness|perinasal irritation|unable to assess|reports being able to use both nostrils|reports no tenderness with applying pressure to sinus areas"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance with good symmetrical movements|moist oral mucosa without lesions|unable to assess|reports dry mouth"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="speaks in clear and unmuffled voice|audible congestion in voice|audible hoarseness present|nasal sounding voice|no stridor||reports pharynx w/o swelling or exudates|reports pharyngeal erythema|reports pharyngeal exudates|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="no visible thyromegaly or other masses|able to move neck in all directions without pain||unable to assess|reports no enlarged/tender cervical lymph nodes on self-palpation|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal respiratory effort|no tachypnea apparent|speaking in full sentences|no audible wheezing||symmetrical chest expansion||unable to assess|reports respiratory distress|reports chest pain with breathing|audible coughing|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="unable to assess|reports pulse to be regular and of normal rate|reports no LE edema|reports no calf tenderness||reports tachycardia|reports irregular heart rhythm|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="unable to assess|no focal abdominal tenderness elicited upon self-palpation||reports diffuse tenderness over entire abdomen w/o RRG|reports direct non-rebound focal tenderness|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="unable to assess|reports no suprapubic tenderness on self-exam|reports no CVAT on self-exam|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="moves all extremities with good ROM for age|no visible gross deformity||unable to assess|reports full weight-bearing|reports no bony tenderness in affected area|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="no tremor visible|normal concentration and attention|memory grossly intact||reports no changes in balance or coordination|no involuntary movements||tremor|tardive dyskinesia|tics|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm, pleasant, respectful|cooperative||poor cooperation|guarded|anxious|irritable|frustrated|labile|sighing|crying|agitated|raising voice|argumentative|hostile|forceful|demanding particular medication, test, referral, or accommodation||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles|threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|standing up|"][textarea cols=70 rows=1]

Speech/Vocalization:
[checkbox name="speech" value="normal for age|clear & coherent||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||perseveration|flight of ideas|repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]


OFFICE DIAGNOSTICS:
[checkbox name="office" value="none||rapid strep NEG|rapid strep POS|rapid flu NEG|rapid flu POS|CXR|"][textarea cols=70 rows=1]

[comment memo="Dx:
viral syndrome
influenza
rhinitis
sinusitis
otitis media
otitis externa
laryngitis
tonsillitis
pharyngitis
dyspnea
acute bronchitis
acute bronchospasm"]

A/P:
[textarea cols=70 rows=4]

PLAN OF CARE:
[checkbox name="discussed" value="POA risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||patient/family did not agree with my POA/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="OTC|paper|electronic|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|previous visits|previous laboratory/diagnostic studies|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs,exam findings, recommendations, reporting medication side effects to clinic immediately, appropriate follow up with PCP|rest/hydration|proper/timely abx use|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified||poor cooperation with exam|lack of motivation|negative attitude to diagnostic impression & proposed tx|incomplete history|vague shifting complaints|history not supported by objective findings||poor compliance with POC|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds||frequent ER/UC visits|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse||perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="RTC or see PCP as discussed, sooner if condition worsens/persists or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx||RTC 24 hours|RTC 48 to 72 hours|RTC 1 week||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]