4 – Derm

HISTORY: 
[checkbox name="historian" value="provided by patient|SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA||complete history unobtainable d/t poor effort/affect|complete history unobtainable d/t cognitive changes or lack of knowledge|complete history unobtainable d/t language skills|"][textarea cols=70 rows=3]
CC:
[checkbox name="cc" value="redness|rash|skin lesion|tender area|swollen area|possible insect bite|suspicious mole|acne|"][textarea cols=70 rows=1]
LOCATION: [select name="Q2" value="generalized|localized|acral|photodistributed||scalp|face|forehead|eyebrow|chin|cheek|lip||axillary|upper arm|forearm|hand|finger||intertriginous||inguinal|buttock|perirectal|thigh|leg|ankle|foot|toe||neck|trunk|chest|back|"][conditional field="Q2" condition="(Q2).is('other - ')"][text][/conditional][checkbox value="left|right||upper|lower||first|second|third|fourth|fifth||proximal|distal||medial|lateral||dorsal|ventral||midline|"][textarea cols=40 rows=1]
QUALITY:
[checkbox name="quality" value="itchy|painful|burning|oozing|painless|"][textarea cols=70 rows=1]
STATED CAUSE:
[checkbox name="cause" value="contact exposure|new medication|possible food-borne|insect bite|associated with infectious illness|new topical medication|new oral medication|trauma|sexual exposure|surgical procedure||unknown|"][textarea cols=70 rows=1]
HPI:
[checkbox name="hpi" value="no similar sx previously|similar sx previously||started just prior to arrival|started today|started yesterday|started days ago|started months ago||sx increasing in severity|sx persist|sx decreasing in severity|spreading||taking OTC, not helping|taking ABX, not helping|taking OC, not helping|taking spironalactone, not helping||not taking any medications|"][textarea cols=70 rows=1]
TETANUS:
[checkbox name="tetanus" value="up to date|less than five years ago|5-10 years ago|greater than 10 years ago|unknown"]
RECENT HISTORY: [textarea cols=40 rows=1]
[+] reported  [-] not reported
[checklist name="recent" value="PCP visit|ER/UC visit|hospitalization|travel|ID exposure|surgery/procedure"]
PMSH:
[checkbox name="pmh" value="reviewed||sick contact|school|travel|surgery|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS:
[+] reported  [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="const_symptoms" value="objective fever|subjective fever|chills|fatigue|weight loss"]
EYES: [textarea cols=40 rows=1]
[checklist name="eye_symptoms" value="decrease in vision|photophobia|redness/irritation|discharge|lid swelling"]
EARS: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|pressure|discharge|wax"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|PND|congestion|sinus pressure|bleeding"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="sores|tongue pain/swelling|toothache"]
THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="sore throat|odynophagia|dysphagia|hoarseness"]
NECK: [textarea cols=40 rows=1]
[checklist name="neck_symptoms" value="pain|stiffness|swelling|swollen glands"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|SOB|palpitations|ankle swelling|ankle discoloration|varicose veins|leg cramps"]
CHEST/RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="chest tightness|rib pain|cough"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="nausea|vomiting|bloating|heartburn|gas|abdominal pain|constipation|diarrhea"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|retention|incontinence|genital lesion/discharge"]
MSK: [textarea cols=40 rows=1]
[checklist name="msk_symptoms" value="neck/back pain|chronic pain/meds|localized joint pain/deformity|generalized joint pain|localized muscle/soft tissue pain/swelling|myalgias"]
NEURO: [textarea cols=40 rows=1]
[checklist name="neuro_symptoms" value="dizziness|poor balance|abnormality of walk|focal weakness|blackouts|seizures|tingling/numbness"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss|insomnia"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia"]
ALLERGIES/IMMUNE: [textarea cols=40 rows=1]
[checklist name="allergy_symptoms" value="atopy|food allergies|autoimmune dz|h/o cancer"]



Appearance:
[checkbox name="appearance" value="well-appearing|alert|non-toxic|normal WOB||allows exam|crying but consolable||ill-appearing|tired-looking|diaphoretic||poor cooperation with exam||drowsy|appears impaired|slumped|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="warm, dry|normal turgor||tattoos|body piercings||pallor|cyanosis|poor turgor|diaphoresis|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="normocephalic, atraumatic|no facial tenderness|symmetrical face|CN grossly intact|"][textarea cols=70 rows=1]

Eyes:
[checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, EOM intact without nystagmus|visual acuity grossly intact|corneas clear||wears glasses|wears contacts||conjunctival injection|epiphora|conjunctival exudate||allergic shiners|dennie lines||palpebral edema/exudates|"][textarea cols=70 rows=1]

Ears:
[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without erythema or discharge|TMs normal in appearance||tragal tenderness|swelling of external auditory canal|pustule in canal|cerumen in canal|TM obscured by cerumen||HOH|hearing aid(s)||TM red|pus/fluid behind TM|TM bulging|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|mucosa pink & moist||allergic salute|deviated septum||mucosal edema|clear discharge|purulent nasal drainage|"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="tongue normal in appearance w/o lesions and with good symmetrical movements|moist oral mucosa without lesions||upper denture|lower denture||oral ulcers|gum swelling|tooth decay|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates||hoarseness|pharyngeal erythema w/o exudates|"][textarea cols=70 rows=1]

Neck:
[checkbox name="neck" value="symmetric with free painless ROM|no LAD||anterior LAD|posterior LAD||nuchal tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|no retractions|clear and equal breath sounds bilaterally||chest wall atraumatic and non-tender|no axillary or supraclavicular LAD||SOB|decreased breath sounds|expiratory wheezing|crackles||poor effort|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses||tachycardia|irregular heart rhythm|systolic murmur||calf tenderness|ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="not examined|normal visual inspection, no distension||normal active bowel sounds|soft non-tender||protruding|surgical scar|umbilical hernia||diffuse tenderness over entire abdomen w/o RRG|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined|no suprapubic tenderness|no CVAT bilaterally||normal external genitalia||no inguinal LAD|no urethral discharge|"][textarea cols=70 rows=1]

MSK:
[checkbox name="spine" value="no gross deformities, moves all extremities with good ROM for age|full weight-bearing|normal curvature & ROM in C- & L-spine for patient’s age|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact||balance & coordination grossly intact|normal speech|no gross motor deficits||sensation symmetrical & grossly intact|extremities strong w/o atrophy, tremor or fasciculations||antalgic gait|wide gait|shuffling gait|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful||cooperative with exam|poor cooperation with exam||guarded|anxious|fearful|suspicious|hypervigilant||irritable|frustrated|restless||labile|sighing|crying||agitated|raising voice||defensive|argumentative|hostile||forceful|intense|euphoric||insisting on particular medication, test, referral, or accommodation||withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements||tremor|tardive dyskinesia|tics||bradykinetic|fidgeting|picking skin|twirling hair|cracking knuckles||threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard||shaking extremities|clenching fists|intense staring||standing up and/or pacing|opening door to hallway|exited exam room during exam|"][textarea cols=70 rows=1]

Speech/Vocalization:
[checkbox name="speech" value="age-appropriate|clear & coherent|normal rate & rhythm||slurred|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||repetitive questions|cursing, swearing|criticisms of staff|verbal threats|"][textarea cols=70 rows=1]
Lesion:
[checkbox name="lesion" value="single lesion|multiple discrete lesions|multiple grouped lesions||symmetrical|unilateral||macular|patch|papular|plaque|maculopapular|follicular|urticarial|targetoid|vesicular|pustular||erythema|rash|purpura|wheel/hives|swelling|nodule/mass|abscess|burn|scar|erosion|desquamation|burrow|fissure||firm|soft|warm|tender|oozing|deep|mobile|pointing|fluctuant|painful||linear|annular|arcuate|serpiginous|reticular||red|hyperpigmented|hypopigmented|purpuric/non-blanching|blanching|uniform color|several colors||smooth|sandpaper-like|crusty|scaly||sharply-demarcated borders|indistinct borders||with surrounding erythema|with surrounding induration|with lymphangitis|with satellites|"][textarea cols=70 rows=1]

OFFICE DIAGNOSTICS:
[checkbox name="office" value="none|"][textarea cols=70 rows=1]

[comment memo="DX:
pityriasis rosea
drug rash
contact dermatitis
eczema
rosacea
erythema multiforme
hives
impetigo
streptococcal associated rash
acne
hidradenitis suppurativa
insect bite(s)
scabies
herpes zoster
psoriasis
cellulitis
sebaceous cyst
pilonidal cyst"]

A/P:
[textarea cols=90 rows=4]

PLAN OF CARE:
[checkbox name="poc" value="POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|verbalized understanding of and agreement with POC, discharge & f/u instructions||did not agree with my POC/recommendations – will seek second opinion/further care elsewhere|"][textarea cols=70 rows=1]

RX:
[checkbox name="order_RX" value="none|electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=70 rows=1]

LABS:
[checkbox name="order_lab" value="none|CBC|CMP|UA||STI|UDS|throat cx|skin cx|"][textarea cols=70 rows=1]
 
REFERRALS:
[checkbox name="order_refer" value="none|dermatology|"][textarea cols=70 rows=1]

REVIEWED:
[checkbox name="reviewed" value="MA notes|med list|previous visits/results|specialty reports|hospital discharge|"][textarea cols=70 rows=1]

INSTRUCTED ON:
[checkbox name="instructions" value="vital signs/exam findings/recommendations|appropriate follow up|reporting medication side effects immediately||laboratory/diagnostic studies|specialty consults|"][textarea cols=70 rows=1]

FOLLOW UP:
[checkbox name="follow" value="RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, PRN||24 hours|48 hours|72 hours|1 week|"][textarea cols=70 rows=1]

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|history not supported by objective findings||poor compliance with POC|multiple comorbidities|polypharmacy|lack of interest in nonpharmacologic therapies|overwhelming focus on Rx drugs|intolerance of multiple meds||frequent ER/UC visits|altered mental status|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse||perseveration|flight of ideas||preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="home|referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left facility before being discharged|asked to leave clinic|"][textarea cols=70 rows=1]