This visit was performed via telemedicine. The patient confirmed knowledge of the limitations of the use of telemedicine were verbally confirmed by the provider. Verification of patient identity was established. Verbal consent was obtained for medical treatment in lieu of coronavirus related emergency.
The patient is being interviewed via [select name="variable_1" value="Phone consult|Video and Audio consult - Doxy.me|Other mode of Video consultation"]
Patinet complains of [textarea name="variable_1" default=""]
Patient had the symptmos x [select name="variable_2" value="1|2|3|4|5|6|7"][select name="variable_3" value="days|weeks|months"].
Patient denies[checkbox name="variable_10" value="subjective fever|chills|symptoms|cough|sore throat|body aches|headache|facial pain|nausea|vomiting|diarrhea|abdominal pain|dyspnea on exertion or at rest|chest pain|lower ext edema|hemoptasis|sore throat |pain with neck movement|Pain with opening mouth|dysphagia"]
COVID-19 QUESTIONS - quick screening. [comment memo="COVID-19 QUESTIONS"] Documented fever: [select name="variable_5" value="NO|YES"] Close contact with person with confirmed or suspected COVID-19: [select name="variable_6" value="NO|YES"] Travel to high risk COVID-19 areas per current local guidance: [select name="variable_7" value="NO|YES"]
[comment memo="STREP SCREENING"] Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? [select name="Centor" value="no|YES"][comment memo="Choose 'yes' to bring up Centor Criteria"][conditional field="Centor" condition="(Centor).is('YES')"]
Denies: [checkbox name="variable_18" value="dyspnea on exertion|subjective fever|productive cough|myagl"]
Modified Centor Score [select name="Q1Fever" value="No (0 points)=0|YES (1 point)=1"] <-- History of fever or measured temperature > 100.4 degrees F [select name="Q2Cough" value="Cough is present (0 points)=0|COUGH IS ABSENT (1 point)=1"] <-- Presence of coughing [select name="Q3Nodes" value="No (0 points)=0|YES (1 point)=1"] <-- Tender anterior cervical nodes [select name="Q4Tonsil" value="No (0 points)=0|YES (1 point)=1"] <-- Tonsillar swelling or exudates [select name="Q5Age" value="< 15 years (1 point)=1|15 to 45 years (0 points)=0|> 45 years (-1 point)=-1"] <-- Age Score --> [calc value="score=(Q1Fever)+(Q2Cough)+(Q3Nodes)+(Q4Tonsil)+(Q5Age)" memo="score"][/conditional]
Diagnostic rationale, follow up instructions, and strict precautions/indications for emergent direct evaluation were discussed with the patient. The patient agrees with the plan, and understands to follow up with their primary care physician or other healthcare provider within 48-72 hours for reevaluation for persistent or worsening symptoms.