Infeksion prova

[text size="3"]yo [select name="Sex" value="M|F"] presenting with:
[comment memo="Initial questions"]
-Sx include: [checkbox name="URTI" value="fever|cough|nose secretions|ear pain|lack of appetite|sore throat|pain with swallowing|other-"][conditional field="URTI" condition="(URTI).is('other-')"]
[text size="50"][/conditional]
[checkbox name="variable_2" value="for the past 1 day.|for the past 2 days.|for the past 3 days."] [text name="variable_3" default=""].
[conditional field="URTI" condition="(URTI).is('fever')"][comment memo="Fever related questions"] 
The fever has been as high as [text name="variable_4" default=" "] [checkbox name="variable_5" value="38C|38.5C|39C|39.5C |40C "] and has been treated with [text name="variable_7" default=""][checkbox name="variable_6" value="Ibuprofen|Paracetamol"][text name="variable_27" default=" "] , [checkbox name="variable_8" value="with good results.| without result."][/conditional]
[conditional field="URTI" condition="(URTI).is('cough')"][comment memo="cough specific questions"]-Cough is [select name="prod" value="non-productive|productive"][conditional field="prod" condition="(prod).is('productive')"]
-Cough started when/while [text memo="inciting event" size="80"]
-Remedies/medicines attempted: [text size="80"]
-Effect of attempted remedies/medicines: [text size="80"]
-Since onset, sx have [select value="gotten better|gotten worse|stayed about the same"]
-Patient describes severity is [select value="minimal|moderate|severe"]
-Patient feels cough at nighttime [select value="not significantly affecting sleep|preventing adequate sleep"]
-Patient reports [select value="no known|known"] sick contacts at home, school, or work. [text size="40"]
-Other associated symptoms:
--[select value="no|YES"] <-chest pain with coughing
--[select value="no|YES"] <-coughing up blood
--[select value="no|YES"] <-fever/chills
--[select value="no|YES"] <-body aches
--[select value="no|YES"] <-hoarseness
--[select value="no|YES"] <-sore throat
--[select value="no|YES"] <-runny/stuffy nose
--[select value="no|YES"] <-ear pain
--[select value="no|YES"] <-sinus pain
--[select value="no|YES"] <-itchy/watery eyes
--[select value="no|YES"] <-pain with swallowing
--[select value="no|YES"] <-feeling of lump in throat (globus sensation)
-Hx of these conditions:
--[select value="no|YES"] <-recent cold
--[select value="no|YES"] <-allergic rhinitis
--[select value="no|YES"] <-non-allergic rhinitis
--[select value="no|YES"] <-frequent sinus infection 
--[select value="no|YES"] <-asthma
--[select value="no|YES"] <-frequent pneumonia
--[select value="no|YES"] <-frequent bronchitis
--[select value="no|YES"] <-GERD
--[select value="no|YES"] <-head/neck/throat/thyroid/lung cancer
--[select value="no|YES"] <-tuberculosis or positive tuberculin skin test
--[select value="no|YES"] <-Diabetes Mellitus

Appetite is [checkbox name="variable_18" value="normal.|decreased.|lower than normal."]
Pt is [checkbox name="variable_9" value="active.|tired.|irritated."]
No [checkbox name= value="sore throat| cough|nasal congestion|rhinorrhea| fever|fatigue|headache|abdominal pain|diarrhea|ear pain| facial pain|SOB |dyspnea|headache"].
The patient has [checkbox name="variable_10" value="been exposed to ill contacts.|not been exposed to ill contacts."] [checkbox name="variable_11" value="Attends day care."]
[checkbox memo="Me shume" name="B" value=""][conditional field="B" condition="(B).is('')"][textarea]Allergies

General: The patient is alert and in [checkbox name="variable_12" value="no distress|mild distress|moderate distress"] [text name="variable_25" default=""].
Skin: [checkbox name="variable_14" value="wnl|Good turgor|no rash|no unusual bruising"][text name="variable_26" default=""].
Eyes: [checkbox name="variable_13" value="wnl|Conjunctiva clear|sclera non-icteric|PERRL"] [text name="variable_13" default=""].
Ears: [checkbox name="variable_15" value="wnl|No tenderness|EACs clear|TMs translucent & mobile, ossicles nl appearance|hearing intact"] [text name="variable_16" default=""].
Nose [checkbox name="variable_17" value="wnl| No external lesions| no nasal discharge| Mucosa non-inflamed| septum and turbinates normal"][text name="variable_17" default=""].
Mouth: [checkbox name="variable_19" value="wnl|Mucous membranes moist| no mucosal lesions"][text name="variable_19" default=""].  
Pharynx: [checkbox name="variable_20" value="wnl|Mucosa non-inflamed| no tonsillar hypertrophy or exudate"] [text name="variable_20" default=""].
Neck: [checkbox name="variable_21" value="wnl|Supple.| Without adenopathy.| Thyroid non-enlarged and non-tender"] [text name="variable_21" default=""].
Heart: [checkbox name="variable_22" value="wnl|S1+S2+0| Regular Rate and Rhythm.| no murmur or gallop"] [text name="variable_22" default=""].
Lungs: [checkbox name="variable_23" value="wnl|Clear to auscultation| Normal vesicular breath sounds bilaterally.| No wheezes,rales or rubs"] [text name="variable_23" default=""]. 
Abdomen: [checkbox name="variable_24" value="wnl|Bowel sounds normal| no tenderness| no organomegaly"] [text name="variable_24" default=""].

[checkbox name="variable_28" value="Fever|Fever unspecified|Viral URI"] 

[checkbox name="variable_30" value="Explained findings to the parent|Explained findings to the pt"]
Use[text name="variable_32" default=" ml"] [checkbox name="variable_31" value="of Ibuprofen 100mg/5ml|Ibuprofen|every 8 hours"] and [text name="variable_34" default=" ml"] [checkbox name="variable_33" value="Paracetamol 120mg/5ml|Paracetamol| every 6 hours| use both interchangeably every 4 hours"].
[checkbox name="variable_38" value="Advised to come back if fever lasts more than 3 full days |Advised to bring child back if symptoms change or parents are worried| Recheck if not improved in five days or sooner if worsening. "]. [checkbox name="variable_35" value="Pt|Parents"] verbalized understanding and agreement
yo presenting with:
Initial questions
-Sx include:

cough specific questions-Cough is

Appetite is
Pt is
No .
The patient has
Me shume

General: The patient is alert and in .
Skin: .
Eyes: .
Ears: .
Nose .
Mouth: .
Pharynx: .
Neck: .
Heart: .
Lungs: .
Abdomen: .



Use and .
. verbalized understanding and agreement

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.7, 89 form elements, 39 boilerplate words, 23 text boxes, 1 text areas, 28 checkboxes, 29 drop downs, 3 comments, 5 conditionals, 157 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

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

More SOAPnotes by this Author: