Pulmonology
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 1 Average: 5]
approximately 42 views in the last month.
Symptoms:
[checkbox name="Symptoms" value="Subjective fever|Chills|Congestion|Rhinorrhea|Sore Throat|Myalgias|Dry cough|Productive cough|Headache|Nausea|Vomiting|Diarrhea |Fatigue|SOB|Dysgeusia|Anosmia"]

Therapies tried:
[checkbox name="Therapies" value="Antipyretics|Cough meds|Nothing"]

High Risk Conditions:[text name="Highriskconditions" default="see problem list"]

Symptoms are [select name="variable_4" value="IMPROVING|WORSENING|STAYING THE SAME"] since onset

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]
COVID-19 QUESTIONS: Documented fever: [select name="variable_1" value="NO|YES"]
Close contact with person with confirmed or suspected COVID-19: [select name="variable_2" value="NO|YES"]
Travel to high risk COVID-19 areas per current local guidance: [select name="variable_3" value="NO|YES"]

PHYSICAL EXAM

Appearance:

well-appearing, alert, non-toxic, normal WOB, no acute distress



Skin:

no visible rashes



Head/Face:

normocephalic, symmetrical face



Nose:

reports being able to use both nostrils, reports no tenderness with applying pressure to sinus areas



Throat:

speaks in clear and unmuffled voice, reports pharynx w/o swelling or exudates



Neck:

no visible thyromegaly or other masses, able to move neck in all directions without pain



Chest/Lungs:

normal respiratory effort, no tachypnea apparent, speaking in full sentences, no audible wheezing



CV:

reports pulse to be regular and of normal rate, reports no LE edema, reports no calf tenderness



Neuro:

no tremor visible, normal concentration and attention, memory grossly intact



Behavior:

calm, pleasant, respectful, cooperative



Speech/Vocalization:

normal for age, clear & coherent

Are you so breathless that you are unable to speak more than a few words?
[checklist name="variable_1" value="NO|YES"]
Are you breathing harder or faster than usual when doing nothing at all?
[checklist name="variable_1" value="NO|YES"]
Are you so ill that you’ve stopped doing all of your usual daily activities?
[checklist name="variable_1" value="NO|YES"]





UC course and MDM:

Diagnostic Impression:

Viral illness
Flu-like syndrome
Exposure to Covid-19

Management: See orders

Testing Ordered:
[checkbox name="Testing" value="Rapid flu|Rapid Strep|Covid/Influenza|CBC|Radiography Chest| Chest CT| D-Dimer|LFT|None"]




Patient is not currently on respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care. There is no moderate acuity with extra risk factors (pneumonia, immunosuppressed, elderly, comorbidities), complicated social situation, worsening symptoms > 10 days out.

Please go to an UC or ED of your choice if you experience:
Trouble breathing
Persistent chest pain or pressure
Inability to stay awake
New confusion
Blue lips or face
Symptoms:


Therapies tried:


High Risk Conditions:

Symptoms are since onset

STREP SCREENING: Is sore throat the main complaint without concurrent cold-like symptoms (nose/eyes/etc)? Choose 'yes' to bring up Centor Criteria
COVID-19 QUESTIONS: Documented fever:
Close contact with person with confirmed or suspected COVID-19:
Travel to high risk COVID-19 areas per current local guidance:

PHYSICAL EXAM

Appearance:

well-appearing, alert, non-toxic, normal WOB, no acute distress



Skin:

no visible rashes



Head/Face:

normocephalic, symmetrical face



Nose:

reports being able to use both nostrils, reports no tenderness with applying pressure to sinus areas



Throat:

speaks in clear and unmuffled voice, reports pharynx w/o swelling or exudates



Neck:

no visible thyromegaly or other masses, able to move neck in all directions without pain



Chest/Lungs:

normal respiratory effort, no tachypnea apparent, speaking in full sentences, no audible wheezing



CV:

reports pulse to be regular and of normal rate, reports no LE edema, reports no calf tenderness



Neuro:

no tremor visible, normal concentration and attention, memory grossly intact



Behavior:

calm, pleasant, respectful, cooperative



Speech/Vocalization:

normal for age, clear & coherent

Are you so breathless that you are unable to speak more than a few words?

Are you breathing harder or faster than usual when doing nothing at all?

Are you so ill that you’ve stopped doing all of your usual daily activities?






UC course and MDM:

Diagnostic Impression:

Viral illness
Flu-like syndrome
Exposure to Covid-19

Management: See orders

Testing Ordered:





Patient is not currently on respiratory distress/failure, multi-organ failure, rapid disease progression requiring escalating supportive care. There is no moderate acuity with extra risk factors (pneumonia, immunosuppressed, elderly, comorbidities), complicated social situation, worsening symptoms > 10 days out.

Please go to an UC or ED of your choice if you experience:
Trouble breathing
Persistent chest pain or pressure
Inability to stay awake
New confusion
Blue lips or face

Result - Copy and paste this output:
Questions/General site feedback

Send Feedback for this SOAPnote

This site uses Akismet to reduce spam. Learn how your comment data is processed.

More SOAPnotes by this Author: