Subjuctive and Objective

[link url="https://www.soapnote.org" memo="SOAPnote Home"]cc: [text size="50"]
HPI: [text size="3"]yo [select value="M|F"] presents to [select value="ED|clinic"] for [textarea]


ROS: [comment memo="Use freetext to explain {+}s if needed"]
Constitutional- [select value="(-)|{+}"]fever, [select value="(-)|{+}"]chills, [select value="(-)|{+}"], Fatigue [select value="(-)|{+}"]malaise, [select value="(-)|{+}"]unexplained wt gain/loss [text size="60"]
SKIN- [select value="(-)|{+}"]rash/eruption, [select value="(-)|{+}"]new moles/lumps/masses, [select value="(-)|{+}"]itching  [text size="60"]
HEENT- [select value="(-)|{+}"]vision/hearing/smell changes, [select value="(-)|{+}"]nose/throat/neck symptoms [text size="60"]
RESP- [select value="(-)|{+}"]cough, [select value="(-)|{+}"]SOB, [select value="(-)|{+}"]wheezing, [text size="60"]
CV- [select value="(-)|{+}"]chest pain, [select value="(-)|{+}"]palpitations, [select value="(-)|{+}"]previous MI, [select value="(-)|{+}"]murmur [text size="60"]
GI- [select value="(-)|{+}"]abd pain/[select value="(-)|{+}"]N/[select value="(-)|{+}"]V/[select value="(-)|{+}"]diarrhea/[select value="(-)|{+}"]constipation [text size="60"]
GU- [select value="(-)|{+}"]urinary frequency/urgency/pain [text size="60"]
MALE REPRO- [select value="(-)|{+}"] ED, [select value="(-)|{+}"]testicle mass, [select value="(-)|{+}"], performs self exams [text size="60"]
GYNECOLOGIC- [select value="(-)|{+}"]LMP, [select value="(-)|{+}"]vaginal discharge/itching, [select value="(-)|{+}"], dysmenorrhea [text size="60"]
MSK- [select value="(-)|{+}"]new/unusual muscle aches/pains/stiffness/Swelling [text size="60"]
NEURO- [select value="(-)|{+}"]memory change, [select value="(-)|{+}"]seizures, [select value="(-)|{+}"], numbness [select value="(-)|{+}"]syncope/dizziness, [select value="(-)|{+}"]falls [text size="60"]
PSYCH- [select value="(-)|{+}"]Anxiety/Nervousness, [select value="(-)|{+}"]mood changes, [select value="(-)|{+}"], sadness/depression [select value="(-)|{+}"]anhedonia, [select value="(-)|{+}"]suicidal thoughts [text size="60"]

PMHx: [textarea]

Home Meds: [select name="Meds" value="see med rec|listed as follows"]
[conditional field="Meds" condition="(Meds).isNot('see med rec')"][textarea cols="60" rows="10"]
[/conditional]
Allergies: [select name="Allergies" value="NKDA|listed- "][conditional field="Allergies" condition="(Allergies).isNot('NKDA')"][textarea cols="60" rows="3"][/conditional]

PSHx: [textarea]

FMHx: [textarea]

Soc: 
-Tobacco- [select name="Tobacco" value="denies/never|previous-|current-"][conditional field="Tobacco" condition="(Tobacco).is('previous-')"][text size="3"]ppd x [text size="4"]yrs, quit [text size="4"]yrs ago, denies current use[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][text size="3"]ppd x [text size="4"]yrs[/conditional]
-EtOH- [select name="EtOH" value="denies/never|previous-|current-"][conditional field="EtOH" condition="(EtOH).is('current-')"][text size="3"] [select value="cans of beer|glasses of wine|shots of whiskey"] [select value="on average daily|on weekends only|rarely on special occasions"] for [text size="4"]yrs[/conditional][conditional field="EtOH" condition="(EtOH).is('previous-')"] quit [text size="4"] years ago, denies current use[/conditional]
-Illicit drugs- [select name="illicitdrugs" value="denies/never|previous-|current-"][conditional field="illicitdrugs" condition="(illicitdrugs).is('previous-')"][text size="50"] x [text size="4"]yrs, quit [text size="4"]yrs ago[/conditional][conditional field="Tobacco" condition="(Tobacco).is('current-')"][text size="50"] x [text size="4"]yrs[/conditional]
-Living situation- [text default="lives with" size="60"]
-Sexual History- [textarea]
-Travel History- [textarea]


Physical Exam: [comment memo="Use freetext for pertinent PE abnormals"]
Vitals- [select name="Vitals" value="reviewed/stable|reviewed/pertinent for- "][conditional field="Vitals" condition="(Vitals).is('reviewed/pertinent for- ')"][text default="BP *, HR *, RR *, T *, SpO2 * % on *L" size="60"][/conditional]
GEN- [text size="60"] [checkbox value="well developed|well nourished|A&Ox4|NAD"]
HEENT- [text size="60"] [checkbox value="Normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent|mucous membranes moist|throat nonerythematous/noninjected|good dentition"]
Neck- [text size="60"] [checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"]
CHEST- [text size="60"] [checkbox value="Normal rise and fall B/L|No accessory muscle use"]
HEART- [text size="60"] [checkbox value="RRR|normal S1/S2|No M/R/G|No S3/S4 auscultated|no friction rub"]
LUNGS- [text size="60"] [checkbox value="CTAB|Breath sounds equal b/l|no wheezes|no crackles|no rhonchi"]
ABD- [text size="60"] [checkbox value="soft|nontender|nondistended|no voluntary/involuntary guarding|no peritoneal signs|bowel sounds present in all 4 quadrants"]
SKIN- [text size="60"] [checkbox value="warm|dry|intact|no edema|no erythema|no ecchymosis"]
EXT- [text size="60"] [checkbox value="no gross deformities noted|no cyanosis|no nail clubbing | Full ROM"]
NEURO- [text size="60"] [checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"]

EKG- [select name="EKG" value="none|reviewed-"] [conditional field="EKG" condition="(EKG).is('reviewed-')"][checkbox value="normal sinus rhythm|tachycardia|bradycardia|normal axis|left axis deviation|right axis deviation|PR interval normal|QRS complex normal|No relevant ST segment deviation/elevation in contiguous leads|QT interval not prolonged"] [text size="80"][/conditional]

LABS- [select name="Labs" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Labs" condition="(Labs).is('reviewed/notable for- ')"][textarea][/conditional]

RADS- [select name="Rads" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Rads" condition="(Rads).is('reviewed/notable for- ')"][textarea][/conditional]