Musculoskeletal & Rheumatology
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Admitting Diagnosis
[text name="variable_1" default=""]

[select name="variable_2" value="Initial Consultation|Readmission"]

Date of consult
[date name="variable_3" default="today"]

History of Presenting Illness
This is a [text name="variable_4" default=""] year old [select name="variable_7" value="male|female|non-binary individual"]
[select name="variable_8" value="with a past medical history of|with no significant past medical history"][conditional field="variable_8" condition="(variable_8).is('with a past medical history of')"]
[checkbox name="variable_6" value="HTN|DM I|DM II|Dyslipidemia|CVA|CAD|RA|OA|Breast CA|Colon CA|Lung CA|"][/conditional]
[conditional field="variable_6" condition="(variable_6).is('')"]
[textarea name="HPI_1" default=""][/conditional]
that was admitted for [text name="variable_1"][comment memo="autocompletes from above"]. A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.
[comment memo="write HPI below"]
[textarea name="variable5" default=""]

Past Surgical History -[select name="Surgical_1" value="Non Contributory|"][conditional field="Surgical_1" condition="(Surgical_1).is('')"][checkbox name="Surgical_2" value="R Hip replacement|L Hip replacement|R knee replacement|L knee replacement"], [textarea name="Surgery_text" default=""][/conditional]

Family History - [select name="Family_1" value="Non Contributory|"][conditional field="Family_1" condition="(Family_1).is('')"][textarea name="Surgery_text" default=""][/conditional]

Prior Functional History - Prior to admission, patient was able to mobilize themselves [select name="Mobility_1" value="Independently|With assistance|"][conditional field="Mobility_1" condition="(Mobility_1).is('')"]
[textarea name="Mobility_text" default=""][/conditional]
Previous Ambulation Devices -
[checkbox name="Ambulation_1" value="No Device|Cane|Walker|Rollator|Wheelchair|Not Previously Ambulating"]
Patient's Activities of Daily Living -
[checkbox name="Mobility_2" value="Dependent/Refused|Maximal Assistance|Moderate Assistance|Minimal Assistance|Setup but otherwise Independent|Independent|Assitance with Homemaking|Assitance with Grooming|"][conditional field="Mobility_2" condition="(Mobility_2).is('')"]
[textarea name="Mobility_text2" default=""][/conditional]

Social History - Patient lives in a [select name="Social_1" value="Private Home|Apartment|Assisted Living Facility|Long Term Care Facility"] with [select name="Social_2" value="1 flight of stairs|5 or fewer steps|multiple flights of stairs|no stairs (ground floor)|elevator"]
[select name="Social_3" value="|Patient admits substance use"][conditional field="Social_3" condition="(Social_3).is('Patient admits substance use')"][textarea name="Social_text3" default=""][/conditional][comment memo="Describe use of Alcohol/Cigarette/Other"]

Pain Medication -
[select name="Pain1" value="Patient states they use OTC pain medication as neeed|"][conditional field="Pain1" condition="(Pain1).is('')"][textarea name="Paintxt1" default=""][/conditional]

Medication -
[select name="Med1" value="I have reviewed the patients medications|"][conditional field="Med1" condition="(Med1).is('')"][textarea name="Medtxt1" default=""][/conditional]

Review of Systems
[comment memo="Default will be negative. Click if positive"]
General
[checklist name="ROS1" value="Weight Change|Fever|Chills|Night Sweats|Fatigue|Skin Changes|Recent Falls"]
[conditional field="ROS1" condition="(ROS1).is('Recent Falls')"]
[textarea name="ROStext1" default=""][/conditional]
Neurological
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness"]
HEENT
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia"]
Cardiovascular
[checklist name="ROS4" value="Chest Pain|Palpitations"]
Respiratory
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath"]
Gastrointestinal
[checklist name="ROS6" value="Nausea|Vomitting|Diarrhea|Constipation|Abdominal Pain"]
Musculoskeletal
[select name= "Msk1" value="|Expanded"][conditional field="Msk1" condition="(Msk1).is('')"][textarea name="Msktxt2" default=""][/conditional][conditional field="Msk1" condition="(Msk1).is('Expanded')"]
Cervical/Thoracic/Lumbar - [textarea name="Msk2" default="denies back pain"]
Joints - [textarea name="Msk3" default="Shoulder/Elbow/Wrist/Finger - Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"]
Upper Extremity - [textarea name="Msk4" default="Upper extremity - Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"]
Hip/Knee/Ankle/Toe - [textarea name="MSk5" default="Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"]
Lower Extremity - [textarea name="Msk6" default="Denies weakness bilaterally, denies range of motion limitations bilaterally, denies pain bilaterally"]
[/conditional]

Physical Exam [comment memo="Please write in Vitals"]
Vital Signs - [textarea name="VS1" default="BP- mmgHg T- °F P- beats/min R- breaths/min"]
General - [textarea name="Pe1" default="No acute distress, Well developed, well nourished, Afebrile"]
Neurological - [textarea name="Pe2" default="Alert and Oriented, Normal mood and affect, Cranial Nerves II-XII grossly intact"]
HEENT - [textarea name="Pe3" default="Head is normocephalic, atraumatic. Bilateral pupils equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses palpated."]
Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits."]
Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremeties. Adequate perfusion. No peripheral signs of cyanosis."]
Gastrointestinal - [textarea name="Pe6" default="Abdomen soft, nontender, nondistended. No guarding or tenderness."]
Musculoskeletal - [textarea name="Mskphys" default=""]

Assessment
[textarea name="Ass1" default=""]

Plan
[textarea name="Plan1" default=""]
[comment memo="Write plan for each problem"]
Admitting Diagnosis




Date of consult


History of Presenting Illness
This is a year old


that was admitted for autocompletes from above. A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.
write HPI below


Past Surgical History -

Family History -

Prior Functional History - Prior to admission, patient was able to mobilize themselves
Previous Ambulation Devices -

Patient's Activities of Daily Living -


Social History - Patient lives in a with
Describe use of Alcohol/Cigarette/Other

Pain Medication -


Medication -


Review of Systems
Default will be negative. Click if positive
General


Neurological

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Musculoskeletal


Physical Exam Please write in Vitals
Vital Signs -
General -
Neurological -
HEENT -
Pulmonary -
Cardiovascular -
Gastrointestinal -
Musculoskeletal -

Assessment


Plan

Write plan for each problem

Result - Copy and paste this output:

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