Musculoskeletal & Rheumatology
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[select name="variable_1" value="Admitting Diagnosis|Long Term Care Patient"]
[conditional field="variable_1" condition="(variable_1).is('Admitting Diagnosis')"] [textarea name="vartxt" default=""][/conditional]

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

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

History of Presenting Illness

[comment memo="write HPI below"]
[textarea name="variable5" default=""]
A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.

Allergies -[textarea name="allergies_1" default="No Known Allergies"]
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 -[textarea name="Surgery_text" default="Non contributory"]

Prior Functional History - Before 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 Prior 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 -
Residence - Patient lives [select name="Residence_1" value="alone|with a spouse|with their family|"] in a [select name="Social_1" value="Private Home|Apartment|Assisted Living Facility|Long Term Care Facility"] [select name="Social_2" value="with 1 flight of stairs|with 5 or fewer steps|with multiple flights of stairs|with no stairs (ground floor)|with an 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="The patient states they use OTC pain medication as needed|"][conditional field="Pain1" condition="(Pain1).is('')"][textarea name="Paintxt1" default=""][/conditional]

Medication -
[select name="Med1" value="I have reviewed the patient's 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="Sleep Disturbances|Fatigue|Skin Changes|Recent Falls|Unable to asses/patient nonverbal"]
[conditional field="ROS1" condition="(ROS1).is('Recent Falls')"]
[textarea name="ROStext1" default=""][/conditional]
Neurological
[checklist name="ROS2" value="Syncope|Headache|Coordination Changes|Weakness| Numbness|Unable to asses/patient nonverbal"]
HEENT
[checklist name="ROS3" value="Vision Changes|Eye Pain|Nasal Congestion|Nasal Discharge|Hearing Changes|Pain in Ear|Dysphagia|Odynophagia|Unable to asses/patient nonverbal"]
Cardiovascular
[checklist name="ROS4" value="Chest Pain|Palpitations|Unable to asses/patient nonverbal"]
Respiratory
[checklist name="ROS5" value="Dyspnea|Cough|Shortness of Breath|Unable to asses/patient nonverbal"]
Gastrointestinal
[checklist name="ROS6" value="Nausea|Vomiting|Diarrhea|Constipation|Abdominal Pain|Unable to asses/patient nonverbal"]
Genitourinary
[checklist name="ROS7" value="Urinary incontinence|Dysuria|Unable to asses/patient nonverbal"]

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 are equal and reactive to light and accommodating. No scleral icterus, no conjunctival pallor. No neck masses were palpated."]
Pulmonary - [textarea name="Pe4" default="Respiratory effort within normal limits."]
Cardiovascular - [textarea name="Pe5" default="Distal pulses 2+ in all extremities. 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=""]

Diagnostic Studies
[checkbox name="dx_1" value="I have reviewed this patient's lab result|No current labs at this time|I have reviewed this patients diagnostic imaging|No diagnostic imaging at this time|"]
[conditional field="dx_1" condition="(dx_1).is('')"][textarea name="dxtxt1" default=""][/conditional]

Assessment
[textarea name="Ass1" default=""]
[checkbox name="Asscheck1" value="R26.9-Repeated Falls|R13.12-Dysphagia,oropharyngeal phase|I69.328-Oth Speech/language deficits following CVA|M13.0-Polyarthritis, unspecified |M86.00-Osteomyelitis|M48.9-Spondylopathy, unspecified|M62.81-Muscle Weakness|M62.40-Contracture of muscle, unspecified|R53.81-Deconditioning|M79.2-Neuropathic pain|R26.2-Walking difficulty|R26.9-Unspecified abnormality of gait or mobility|Z73.6-Decreased ADL|Z74.09-Chairridden|Z74.1-Need assistance with personal care"]


Plan
[textarea name="Plan1" default=""]
[checkbox name="Plancheck1" value="Continue PT, OT to improve the level of function and quality of life|Educated patient on the importance of therapy and exercises while in bed|Progressive gait training with an appropriate level of assistance, with emphasis on safety and endurance|Improve bed mobility and transfers|Ice Pack on painful joint PRN|E-stim|1.8% Lidocaine Patch|4% Lidocaine Patch|5% Lidocaine Patch|Will continue to follow"]





Date of consult


History of Presenting Illness

write HPI below

A consultation was requested to assess rehabilitation needs, develop a rehabilitation plan of care and address rehabilitation medicine diagnoses and their related issues.

Allergies -
Past Surgical History -

Family History -

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

Patient's Prior Activities of Daily Living -


Social History -
Residence - Patient lives in a
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

Genitourinary


Musculoskeletal


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

Diagnostic Studies



Assessment




Plan

Result - Copy and paste this output:

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