Assessment

Assessment

[checkbox name="apDM" memo="Diabetes" value=""][conditional field="apDM" condition="(apDM).is('')"][comment memo="assessment #:"][select name="lineBarriersTC_apDM" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "]Diabetes: [text name="assessment_apDM" size=100 default="Type II; Non-insulin dependent; stable/well controlled with current therapy"]
[/conditional][checkbox name="apHTN" memo="HTN" value=""][conditional field="apHTN" condition="(apHTN).is('')"][comment memo="assessment #:"][select name="lineBarriersTC_apHTN" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][select name="HTNstage" value="Stage II|Stage I|Accelerated |Hypertensive urgency|Hypertensive emergency|"][select name="HTNtype" value=" essential hypertension| secondary Hypertension|"]: [text name="assessment_apHTN" size=100 default="stable/well controlled with current therapy"]
[/conditional][checkbox name="apHTN-Heart-Disease" memo="HTN-Heart-Disease" value=""][conditional field="apHTN-Heart-Disease" condition="(apHTN-Heart-Disease).is('')"][comment memo="assessment #:"][select name="lineBarriersTC_apHTN-Heart-Disease" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "]Hypertensive Heart Disease: [text name="assessment_apHTN-Heart-Disease" size=100 default="stable/well controlled with current therapy"]
[/conditional][conditional field="apAcuteSinusitis" condition="(apAcuteSinusitis).is('')"][comment memo="assessment #:"][select name="lineBarriersTC_apAcuteSinusitis" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "]Acute Rhinosinusitis: 
[comment memo="Originally developed by Mark Morgan"][comment memo="First-line antimicrobial therapy: regular dose amoxicillin/clavulanate. Second-line antimicrobial therapy: high dose amoxicillin/clavulanate; levofloxacin; moxifloxacin (adult); clindamycin AND cefpodoxime OR cefixime; or doxycycline (adult)"] Acute Bacterial Rhinosinusitis Decision Tool
Risk Factors:
[select name="Q1" value="no=0|YES=1"] <-- Signs and symptoms persistent and no improving for 10+ days
[select name="Q2" value="no=0|YES=1"] <-- Severe for 3+ days
[select name="Q3" value="no=0|YES=1"] <-- Worsening or double-sickening 3+ days
[select name="Q4" value="no=0|YES=10"] <-- Risk for resistance (age 65 years, antibiotic use within the past month, prior hospitalization longer than 5 days, comorbidities, or immunocompromised status)
[calc memo="result" value="score=(Q1)+(Q2)+(Q3)+(Q4);score>10?'Symptomatic management AND Second-line antimicrobial therapy':score>1?'Symptomatic management AND First-line antimicrobial therapy':'Symptomatic management'"]
reference:
[link url="//www.ncbi.nlm.nih.gov/pubmed/22438350" memo="#1"] Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File TM Jr, Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012 Apr;54(8):e72-e112.
[/conditional][checkbox memo="freetext assessment" name="OtherADx1" value=""][conditional field="OtherADx1" condition="(OtherADx1).is('')"]
[comment memo="assessment #:"][select name="line1_OtherADx1" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][comment memo="diagnosis"][select value="|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|thyroid atrophy|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___" ][text memo="other (freetext)"]: [textarea name="Details_OtherADx1" memo="assessment details"]
[/conditional][checkbox memo="freetext assessment" name="OtherADx2" value=""][conditional field="OtherADx2" condition="(OtherADx2).is('')"][comment memo="assessment #:"][select name="line2_OtherADx2" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][comment memo="diagnosis"][select value="|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|thyroid atrophy|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___" ][text memo="other (freetext)"]: [textarea name="Details_OtherADx2" memo="assessment details"]
[/conditional][checkbox memo="freetext assessment" name="OtherADx3" value=""][conditional field="OtherADx3" condition="(OtherADx3).is('')"][comment memo="assessment #:"][select name="line3_OtherADx3" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][comment memo="diagnosis"][select value="|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|thyroid atrophy|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___" ][text memo="other (freetext)"]: [textarea name="Details_OtherADx3" memo="assessment details"]
[/conditional][checkbox memo="freetext assessment" name="OtherADx4" value=""][conditional field="OtherADx4" condition="(OtherADx4).is('')"][comment memo="assessment #:"][select name="line4_OtherADx4" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][comment memo="diagnosis"][select value="|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|thyroid atrophy|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___" ][text memo="other (freetext)"]: [textarea name="Details_OtherADx4" memo="assessment details"]
[/conditional][checkbox memo="freetext assessment" name="OtherADx5" value=""][conditional field="OtherADx5" condition="(OtherADx5).is('')"][comment memo="assessment #:"][select name="line5_OtherADx5" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][comment memo="diagnosis"][select value="|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|thyroid atrophy|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___" ][text memo="other (freetext)"]: [textarea name="Details_OtherADx5" memo="assessment details"]
[/conditional][checkbox memo="freetext assessment" name="OtherADx6" value=""][conditional field="OtherADx6" condition="(OtherADx6).is('')"][comment memo="assessment #:"][select name="line6_OtherADx6" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "][comment memo="diagnosis"][select value="|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|thyroid atrophy|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___" ][text memo="other (freetext)"]: [textarea name="Details_OtherADx6" memo="assessment details"]
[/conditional][checkbox memo="Barriers to care" name="OtherADxBarriersTC" value=""][conditional field="OtherADxBarriersTC" condition="(OtherADxBarriersTC).is('')"]
[comment memo="assessment #:"][select name="lineNo_OtherADxBarriersTC" value="| 1. | 2. | 3. | 4. | 5. | 6. | 7. | 8. | 9. | 10. "]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|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|social/cultural barriers||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|"][textarea cols=40 rows=5]
[/conditional]