Per tu perdorur si drejtim
[text size="3"]yo [select name="Sex" value="M|F"] with gastrointestinal symptoms: [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="GI" condition="(GI).is('other-')"] [text size="50"][/conditional] [conditional field="URTI" condition="(URTI).is('fever')"][comment memo="Fever related questions"] [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=""]. 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=" ml"][checkbox name="variable_6" value="Ibuprofen,|Paracetamol"][text name="variable_27" default=" ml"] , [checkbox name="variable_8" value="with good results.| without result."] [text size="50"] [/conditional] History of present illness Chief complaint I have a cough that is really bothering me. Cough productive of sputum Not usually. But in the past few days, yes, I have been coughing up some gunk. Color of sputum It is greenish. Volume of sputum I would say about 1 teaspoon per day. Blood in sputum No. Onset 3–4 months ago. Constant/intermittent It comes and goes. Precipitating events The first time I had it was at one of my gymnastics classes. Nothing special was really going on with me at the time though. Progression It had been the same until about 4 days ago, but then it suddenly got a lot worse. Previous episodes No. Frequency On and off, until 4 days ago. Now I have it several times a day. Alleviating factors Nothing really. Aggravating factors When exercising I will suddenly have a big cough attack and have to stop. It is so annoying. Associated symptoms Sometimes when I have the cough attacks, I also feel like I cannot catch my breath, which is scary. Review of systems specific to recurrent cough Recent travel No. Headache No. Nausea/vomiting No. Fever/chills Hmm, I felt a bit hot in the evening the past 2 days. Night sweats No. Fatigue No. Racing of the heart None. Chest pain For the past 4 days, my cough has been painful. Urinary problems None. Bowel problems None. Sleep problems For the past month, this cough has woken me up several times during the night, so my sleep has not been as good as it normally is. Appetite Normal. Weight changes No. Recent infections Well, I have a cold, if that is what you mean. Symptoms of upper respiratory infection I have had a runny nose for the past 5 days. Exposure to tuberculosis No. Exposure to fumes/dust No. Exposure to animals/pets No. Past medical history, family history, social history Past medical history I have eczema. Allergies I think I am allergic to horses. My eczema has always gotten worse when I have gone riding. Medications I use a couple of different moisturizing creams for my eczema, and when it gets really bad I have to use a hydrocortisone cream. Hospitalizations Never, thank God! Ill contacts No. Past surgical history No. Family history My mom also has eczema. Work I am going to college to become a graphic designer. Home I live in a dorm. Alcohol Sometimes I drink a beer at parties, but I do not drink regularly. Recreational drugs I smoke marijuana sometimes or try one of the pills I get offered at the parties I go to. But I do not take something everyday or anything like that. Tobacco I do not smoke cigarettes, only marijuana once in a while. Exercise I have done gymnastics since I was little, and I am on the college gymnastics team, but now I have trouble getting through practice because of these awful cough attacks. Focused physical examination Washed hands Used respectful draping Head, eyes, ears, nose, and throat examination Inspection of the oropharynx Neck examination Palpation of the lymph nodes of the head and neck Cardiovascular examination Auscultation of the heart Chest examination Inspection of the chest Palpation of the chest Percussion of the lung fields Auscultation of the lungs Examination for fremitus Extremities Inspection of the hands
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.46, 17 form elements, 555 boilerplate words, 7 text boxes, 5 checkboxes, 1 drop downs, 2 comments, 2 conditionals, 28 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote