# Orientation
# CHIEF COMPLAINT: [select name="variable_16" value="***|A|Abdominal Pain|Alcohol Withdrawal|Altered Mental Status / Confusion|B|Bilateral Leg Pain|C|Chronic Obstructive Pulmonary Disease (COPD)|Confusion / Altered Mental Status|D|Diabetes Mellitus|E|Ethanol abuse|F|G|H|I|J|K|L|Left Leg Pain|M|N|O|P|Pulmonary Exacerbation Secondary To Cystic Fibrosis|Q|R|Right Leg Pain|S|Shortness of Breath (SOB)|Sickle Cell Crisis|T|Type I Diabetes|Type II Diabetes|U|V|Vaso-Occlusive Crisis|W|X|Y|Z"] # ——————————————————- | PATIENT PROFILE | ———-——————————————- Patient is a [select name="variable_01" value="***|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100"] year old [select name="variable_02" value="***|female|male|man|woman"] hospital day [select name="variable_29" value="***|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100"] [select name="variable_17" value="***|who presents with a chief complaint of|who is presenting with|who was admitted for|who was electively admitted for evaluation of|who comes in to clinic for follow up of|who comes in to clinic for follow up for"] [select name="variable_03" value="***|A ###|Abdominal Pain|Alcohol Withdrawal|Altered Mental Status / Confusion|B|Bilateral Leg Pain|C|Confusion / Altered Mental Status|D|E|Ethanol Abuse|F|G|H|Herpes Simplex Virus(HSV)|I|J|K|L|Left Leg Pain|M|N|O|Ovarian Cyst|P|Pulmonary Exacerbation Secondary To Cystic Fibrosis|Q|R|Right Leg Pain|S|Shortness of Breath(SOB)|Sickle Cell Crisis|T|U|V|Vaso-Occlusive Crisis|W|X|Y|Z"] with a relevant past medical history significant for [checkbox name="variable_18" value="***|A|abnormal EEG|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|anasarca|aneurysm (intracranial)|anti-phospholipid syndrome (APS)|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|avascular necrosis of the ***|anemia due to blood loss|anemia due to chronic stage 4 renal failure|aortic valve stenosis|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of right humerus|anxiety|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 pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type 2 diabetes|chronic renal allograft nephropathy|cocaine use|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|E|eclampsia|esophageal varices|essential hypertension|ethanol abuse|F|failure to thrive|G|gastritis|gastroesopheal reflux disease (GERD)|H|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|hypertension (HTN)|hypertension (HT) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|I|intracranial aneurysm|J|K|L|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|non-convulsive status epilepticus|O|obstructive sleep apnea (OSA)|osteoarthritis|P| pancreatic cancer|pancreatitis|panic attacks|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|preeclampsia|protienuria|pulmonary embolism|Q|R|recurrent urinary tract infections|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|status epilepticus (non-convulsive)|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|T|thrombocytopenia|type I diabetes|type II diabetes with complication|type II diabetes without complications|U|urinary tract infections (UTI)|ulnar nerve compression|V|venous thromboembolism (VTE)|W|X|Y|Z"]. Other significant but non-pertinent past medical history includes:
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 1, 7 form elements, 30 boilerplate words, 1 checkboxes, 6 drop downs, 155 total clicks
More SOAPnotes by this Author:
Send Feedback for this SOAPnote
You must be logged in to post a comment.