-B{swVq{|``sw2kA}fsvt`E|}awa|~W{{|t~300: {@INPUT Parent with history of cholesterol >300? @SINGLE No Yes, cholesterol testing of child discussed. } Other concerns or worries: {@INPUT Other concerns}2yrplan2 yr IRPl#1 Health Maintenance Normal Growth and Development age 2 years Age specific guidance: {@INPUT guidance given Burn prevention, care near streets, caution around open water, use of car seats, transition from crib to bed, toilet training, night terrors and tantrum information reviewed nutritional guidance day care issues PowerPoint Presentation handout from MD Consult and {@INPUT other handouts/information} } information discussed and/or given. {@INPUT @SINGLE{@REM Close contact with person with TB, live or born in area where TB is common, recent immigrant, family history of TB, exposure to HIV Pos person, foreign visitors, recent resident of correctional facility, foster children?} Tuberculosis Risk: No Tuberculosis Risk: Yes, testing recommended } Return appointment: {@INPUT Next Visit @SINGLE age 3 yr age 4 yr age 5 yr } or sooner if needed3yrchild3 yr HPI#1 Health Care maintenance Child here for a 3 year exam. General description and personality: {@INPUT Child's personality and description} Diet: {@INPUT Diet whole milk 2% milk 1% milk skim milk variety of table foods vitamins fluoride } Sleeping habits: {@INPUT Sleeping at night @SINGLE sleeps through night wakes during night } and {@INPUT nap habits @SINGLE has no naps naps twice a day naps once a day }. Skills developed at the 90th percentile: {@INPUT Development at 90 % washes and dry hands, builds a six-cube tower, half of speech is understandable, and throws ball overhand washes and dry hands DOES NOT WASH AND DRY HANDS (not 90th %) able to build a six-cube tower IS NOT ABLE TO BUILD A SIX-CUBE TOWER (not 90th %) half of speech is understandable HALF OF SPEECH IS UNDERSTANDABLE (not 90th %) } Previous reaction to immunizations: {@INPUT previous immunization reaction @SINGLE no significant reaction has had significant reaction: {@INPUT describe details of reaction to immunizations} } Lead Risk Exposed to housing 1950 or older: {@INPUT Exposed to housing 1950 or older? @SINGLE no YES } Moved to MN from foreign country or major metropolitan area within last 12 months: {@INPUT Moved to MN from foreign country or major metropolitan area within last 12 months? @SINGLE no YES } Parent with history of Cholesterol >300: {@INPUT Parent with history of cholesterol >300? @SINGLE No Yes, cholesterol testing of child discussed } Other concerns or worries: {@INPUT Other concerns are}3yrplan3 yr IRPk#1 Health Maintenance Normal Growth and Development age 3 years Age specific guidance: {@INPUT guidance given Burn prevention, care near streets, caution around open water, use of car seats, transition from crib to bed, use of bike helmet, toilet training, night terrors and tantrum information reviewed. Side effects, risks and benefits of immunizations nutritional guidance day care issues dental PowerPoint Presentation handout from MD Consult and {@INPUT other handouts/information} } information discussed and/or given. Immunizations today: MMR (Measles-Mumps-Rubella) Vision screening: {@INPUT Vision screening done @SINGLE assessed not assessed child uncooperative } Hearing screening: {@INPUT Hearing screening done @SINGLE assessed not assessed child uncooperative } {@INPUT @SINGLE{@REM Close contact with person with TB, live or born in area where TB is common, recent immigrant, family history of TB, exposure to HIV Pos person, foreign visitors, recent resident of correctional facility, foster children?} Tuberculosis Risk: No Tuberculosis Risk: Yes, testing recommended } {@INPUT @SINGLE{@REM Exposed to home built before 1950, before 1978 under renovation, sibling/playmate w/ lead poisoning?} Lead Risk: No Lead Risk: Yes, testing recommended } Return appointment: {@INPUT Next Visit @SINGLE age 5 yr age 4 yr } or sooner if needed3yrshot 3 yr shotOn {@SHORTDATE} was given MMR.4mochild4 mo HPI#1 Health Care maintenance Child here for 4 month exam. General description and personality: {@INPUT Childs personality and description} Diet: {@INPUT Diet nursing every {@INPUT number of hours between feeding} hours nursing every {@INPUT number of hours between feedings} hours and formula every {@INPUT number of hours between feeding}hours formula without iron every {@INPUT number of hours between feeding} hours formula with iron every {@INPUT number of hours between feeding} hours solids vitamins }. Sleeping habits: Wakes {@INPUT times wakes up at night} times during night and has {@INPUT number of daytime naps} naps. T Skills developed at the 90th percentile: {@INPUT Development at 90 % regards hand, puts hands together, squeals, and pushes up regards hand DOES NOT REGARD HAND (not 90th %) puts hands together DOES NOT PUT HANDS TOGETHER (not 90th %) squeals DOES NOT SQUEAL (not 90th %) pushes up DOES NOT PUSH UP (not 90th %) }. Previous reaction to immunizations: {@INPUT previous immunization reaction @SINGLE no significant reaction has had significant reaction: {@INPUT describe details of reaction to immunizations} } Other concerns or worries: {@INPUT Other concerns}4moplan 4 month IRP #1 Health Maintenance Normal Growth and Development age 4 months Age specific guidance: {@INPUT guidance given use car restraints, do not leave near water or where the child can fall, do not use walkers or small toys, avoidance of plastics suffocation and burn prevention reviewed. Side effects, risks and benefits of immunizations nutritional guidance fluoride use{@REM child may need fluoride drops or tablets if primarily breast feeding or using water with too little fluoride (<.3 ppm)} day care issues PowerPoint Presentation handout from MD Consult and {@INPUT other handouts/information} } information discussed and/or given. Immunizations today: HBV-Hib, DTaP, and IPV (Hepatitis B-Haemophilus influenza, Diphtheria-Tetanus, acellular Pertussis and polio) PCV7 (Pneumococcal): {@INPUT Pneumococcal Vaccine @SINGLE desired and given refused }. Return appointment: {@INPUT next visit @SINGLE age 6 months-immunizations with nurse age 6 months-immunizations and visit age 9 months } or sooner if needed.24moshot 4 month shotsOn {@SHORTDATE} HBV-Hib, DTaP, and IPV (Hepatitis B, Haemophlus influenza, Diphtheria, Tetanus, acellular Pertussis and polio) were given.5yrchild5 yr HPI#1 Health Care maintenance Child here for a 5 year exam. General description and personality: {@INPUT Child's personality and description} Diet: {@INPUT Diet whole milk 2% milk 1% milk skim milk solids from the table solid such as {@INPUT Types of solids given} vitamins fluoride } Sleeping habits: Sleeps {@INPUT Sleeps @SINGLE through night wakes during night } and {@INPUT nap habits @SINGLE has no nap nap twice a day nap once a day } Skills developed at the 90th percentile: {@INPUT Development at 90 % dresses without supervision, draws person, defines 5/8 ball, lake, desk, house, banana, curtain, fence, ceiling, and balances on each foot four seconds dresses with supervision DOES NOT DRESS WITH SUPERVISION (not 90th %) defines 5/8 ball, lake, desk, house, banana, curtain, fence, ceiling DOES NOT DEFINE 5/8 BALL, LAKE, DESK, HOUSE, BANANA, CURTAIN, FENCE, CEILING (not 90th %) balances on each foot four seconds DOES NOT BALANCE ON EACH FOOT FOUR SECONDS (not 90th %) } Previous reaction to immunizations: {@INPUT previous immunization reaction @SINGLE no significant reaction has had significant reaction:{@INPUT describe details of reaction to immunizations} } Lead Risk Exposed to housing 1950 or older: {@INPUT Exposed to housing 1950 or older? @SINGLE no YES } Moved to MN from foreign country or major metropolitan area within last 12 months: {@INPUT Moved to MN from foreign country or major metropolitan area within last 12 months? @SINGLE no YES } Parent with history of Cholesterol >300: {@INPUT Parent with history of cholesterol >300? @SINGLE No Yes, cholesterol testing of child discussed } Other concerns or worries: {@INPUT Other concerns are}5yrplan5 yr IRP#1 Health Maintenance Normal Growth and Development age 5 years Age specific guidance: {@INPUT guidance given Burn prevention (matches), care near streets, caution around open water, use of seatbelt information reviewed. Side effects, risks and benefits of immunizations self-esteem issues limit television time use of helmets when riding bike or scooter day care issues PowerPoint Presentation handout from MD Consult and {@INPUT other handouts/information} } information discussed and/or given. Immunizations today: DTaP, and IPV (Diphtheria-Tetanus-acellular Pertussis and polio) Vision screening: {@INPUT Vision screening done @SINGLE assessed not assessed child uncooperative } Hearing screening: {@INPUT Hearing screening done @SINGLE assessed not assessed child uncooperative } Return appointment: {@INPUT next visit @SINGLE age 7 yrs age 9 yrs age {@INPUT age for next return visit} } or sooner if needed65yrshot 5 yr shotsOn {@SHORTDATE} {@INPUT immunizations Standard DTaP, IPV (Diphtheria, Tetanus, acellular Pertussis, oral polio) were given DTaP, IPV, and MMR (Diphtheria, Tetanus, acellular Pertussis, oral polio, Measles Mumps Rubella) were given }.6mochild 6 month HPI#1 Health Care maintenance Child here for 6 month exam. General description and personality: {@INPUT Childs personality and description} Diet: {@INPUT Diet nursing every {@INPUT number of hours between feeding} hours nursing every {@INPUT number of hours between feedings} hours and formula every {@INPUT number of hours between feeding} hours formula without iron every {@INPUT number of hours between feeding} hours formula with iron every {@INPUT number of hours between feeding} hours solids vitamins }. Sleeping habits: Wakes {@INPUT times wakes up at night} times during night and has {@INPUT number of daytime naps} naps. Skills developed at the 90th percentile: {@INPUT Development at 90 % works for toy, reaches for object, turns to voice and pulls to sit works for toy DOES NOT WORK FOR TOY (not 90th %) reaches for object DOES NOT REACH FOR OBJECT (not 90th %) turns to voice DOES NOT TURN TO VOICE (not 90th %) pulls to sit DOES NOT PULL TO SIT (not 90th %) }. Previous reaction to immunizations: {@INPUT previous immunizationss reaction @SINGLE no significant reaction has had significant reaction: {@INPUT describe details of reaction to immunizations} } Other concerns or worries: {@INPUT Other concerns}6moplan 6 month IRP;#1 Health Maintenance Normal Growth and Development age 6 months Age specific guidance: {@INPUT guidance given use of car restraints, supervise around water or where the child can fall, use gates to block stairway, be careful of cords and plants, do not use walkers or allow with small objects and burn prevention reviewed. Side effects, risks and benefits of immunizations nutritional guidance day care issues PowerPoint Presentation handout from MD Consult and {@INPUT other handouts/information} } information discussed and/or given. Immunizations today: DTaP (Diphtheria-Tetanus-acellular Pertussis) PCV7 (Pneumococcal): {@INPUT Pneumococcal Vaccine @SINGLE desired and given refused }. Return appointment: {@INPUT next visit @SINGLE age 9 months age 12 months age 15 months } or sooner if needed.36moshot 6 mo shots^On {@SHORTDATE} DTaP and IPV (Diphtheria, Tetanus, acellular Pertussis and polio) were given.9mochild9 mo HPIp#1 Health Care maintenance Child here for 9 month exam. General description and personality: {@INPUT Childs personality and description} Diet: {@INPUT Diet nursing every {@INPUT number of hours between feeding} hours nursing every {@INPUT number of hours between feedings} hours and formula every {@INPUT number of hours between feeding} hours formula without iron every {@INPUT number of hours between feeding} hours formula with iron every {@INPUT number of hours between feeding} hours solids vitamins fluoride }. Sleeping habits: Wakes {@INPUT times wakes up at night} times during night and has {@INPUT number of daytime naps} naps. Skills developed at the 90th percentile: {@INPUT Development at 90 % feeds self cracker, pincer grip with help, nonspecific da da ma ma, and stands holding on feeds self cracker DOES NOT FEED SELF CRACKER (not 90th %) pincer grip with help NOT ABLE TO HAVE PINCER GRIP WITH HELP (not 90th %) nonspecific da da ma ma DOES NOT HAVE NONSPECIFIC DA DA, MA MA (not 90th %) stands holding on DOES NOT STAND HOLDING ON (not 90th %) } Previous reaction to immunizations: {@INPUT previous immunization reaction @SINGLE no significant reaction has had significant reaction:{@INPUT describe details of reaction to immunizations} } Lead Risk Exposed to housing 1950 or older: {@INPUT Exposed to housing 1950 or older? @SINGLE no YES } Moved to MN from foreign country or major metropolitan area within last 12 months: {@INPUT Moved to MN from foreign country or major metropolitan area within last 12 months? @SINGLE no YES } Other concerns or worries: {@INPUT Other concerns}9moplan 9 month IRPe#1 Health Maintenance Normal Growth and Development age 9 months Age specific guidance: {@INPUT guidance given shoes cover feet and need not be expensive, use of car restraints, biking safety, poisoning and choking information reviewed. Side effects, risks and benefits of immunizations Syrup of Ipecac nutritional guidance day care issues PowerPoint Presentation handout from MD Consult and {@INPUT other handouts/information} } information discussed and/or given. {@INPUT @SINGLE{@REM Exposed to home built before 1950, before 1978 under renovation, sibling/playmate w/ lead poisoning?} Lead Risk: No Lead Risk: Yes, testing recommended } {@INPUT @SINGLE{@REM Close contact with person with TB, live or born in area where TB is common, recent immigrant, family history of TB, exposure to HIV Pos person, foreign visitors, recent resident of correctional facility, foster children?} Tuberculosis Risk: No Tuberculosis Risk: Yes, testing recommended } Immunizations today: Hepatitis B and IPV (polio) Return appointment: {@INPUT next visit @SINGLE age 12 months age 15 months } or sooner if needed.49moshot 9 month shots-On {@SHORTDATE} HBV (Hepatitis B) was given.A asthmahpi asthma HPI| #{@INPUT What problem number is it} Asthma since age {@INPUT age asthma started} The patient has experienced the following symptoms {@INPUT symptoms coughing wheezing shortness of breath chest tightness sputum production URI like symptoms night time wakening no symptoms related to asthma }. The pattern of symptoms are {@INPUT Pattern of symptoms perennial seasonal continual episodic nocturnal exertional }. The onset of the symptoms {@INPUT onset of the symptoms started {@INPUT Time of start of symptoms} has been present daily has continued to become worse is present only on exertion is present only at night has been present {@INPUT days/week} days of the past week has been present {@INPUT days/month} days of the past month has generally been stable } Triggering agents and past year's events: The precipitating factors of the asthma are {@INPUT ppt factors URI mold mite cockroach animal dander pollen smoke perfume chemicals exercise occupational exposure: {@INPUT occupational exposure details} emotional changes: {@INPUT details of emotional changes} drugs: {@INPUT drug type that made worst} foods: {@INPUT food that made worst} changes in weather: {@INPUT weather changes ie: cold or humidity} endocrine changes: {@INPUT endocrine changes ie: menses or pregnancy} }. The home is heated by {@INPUT heating system in home forced air heat wood burning stove steam heat electric heat }. The bedroom {@INPUT bedroom characteristics @SINGLE has been made dust free has not been made dust free }. The family is made up of {@INPUT smokers in family @SINGLE nonsmokers at least one smoker }. The family has {@INPUT animals in home a dog a cat a pet that may cause asthma to be worst no animals in home and the animal is in the sleeping area }. There have been {@INPUT number of hospitalizations past year @SINGLE 0 1 2 3 4 5 more then 5 } hospitalizations, {@INPUT number of emergency room visits past year @SINGLE 0 1 2 3 4 5 more then 5 } emergency room visits, and about {@INPUT number of outpatient visits for asthma@SINGLE 0 1 2 3 4 5 more then 5 } outpatient visits during the past year. Current Management Patient education was received at the {@INPUT education patient education center in {@INPUT Year of patient education} clinic, on the floor }. {@INPUT use of peak flow meter @SINGLE Peak flow meter is used correctly Peak flow meter is used, but needs to have more education Peak flow meter is not used }. {@INPUT use of spacer @SINGLE Spacer is used correctly Spacer is used, but needs to have more education Spacer is not used }. Personal best peak flow was {@INPUT peak flow meter best}. Patient {@INPUT action plan Asthma Action Plan is not needed because of the type of asthma has an Asthma Action Plan has an Asthma Action Plan, but needs more education on using it does not have an Asthma Action Plan will get an Asthma Action Plan this visit }. Patient is aware that all asthmatics are candidates for yearly influenza, once in a lifetime pneumovax, and sometimes Epi-Pen. Details for immunization can be found in PMH. Medication list is current. asthmanursenurse education in asthma:A power point presentation was given reviewing asthma. It covers the basic guidelines for asthma education. The following handouts were given: {@INPUT handouts general asthma information use of a spacer use of a peak flow meter creating a dust free room medication use handouts on {@INPUT misc handouts} }.asthmarxasthma action plahnThe following medications are used in the green zone (80-100% best peak flow): {@INPUT medications used in green zone Beclomethasone (Beclovent or Vanceril): {@INPUT number of puffs of steroid spray} puffs {@INPUT number of times a day} a day Trimcinolone (Azmacort): {@INPUT number of steroid spray puffs} puffs {@INPUT number of times a day} a day Flunisolide (AereoBid): {@INPUT number of steroid puffs} puffs {@INPUT number of times a day} a day Fluticasone (Flovent): {@INPUT number of ug} ug {@INPUT number of times a day} a day Cromolyn (Intal): {@INPUT number of cromolyn puffs} puffs {@INPUT number of times a day} a day. Nedocromil (Tilade): {@INPUT number of tilade puffs} puffs {@INPUT number of times a day} a day. Ventolin: {@INPUT number of ventolin puffs} puffs every four hours Albuterol: {@INPUT number of albuterol puffs} puffs every four hours Maxair: {@INPUT number of maxair puffs} puffs every four hours Proventil: {@INPUT number of ventolin puffs} puffs every four hours Serevent: {@INPUT number of serevent puffs} puffs {@INPUT number of times a day} a day. This is not an emergency drug. It takes a long time to work Atrovent: {@INPUT Atrovent dosage in times per day} puffs a day Accolate: {@INPUT Accolate instructions} Zyflo: {@INPUT Zyflo instructions} Theophyllin: {@INPUT Theophyllin instructions} }. The following medications are used in the yellow zone (60-80% best peak flow): {@INPUT medications used in yellow zone Beclomethasone (Beclovent or Vanceril): {@INPUT number of puffs of steroid spray} puffs {@INPUT number of times a day} a day Trimcinolone (Azmacort): {@INPUT number of steroid spray puffs} puffs {@INPUT number of times a day} a day Flunisolide (AereoBid): {@INPUT number of steroid puffs} puffs {@INPUT number of times a day} a day Fluticasone (Flovent): {@INPUT number of ug} ug {@INPUT number of times a day} a day Cromolyn (Intal): {@INPUT number of cromolyn puffs} puffs {@INPUT number of times a day} a day. Nedocromil (Tilade): {@INPUT number of tilade puffs} puffs {@INPUT number of times a day} a day. Ventolin: {@INPUT number of ventolin puffs} puffs every four hours Albuterol: {@INPUT number of albuterol puffs} puffs every four hours Maxair: {@INPUT number of maxair puffs} puffs every four hours Proventil: {@INPUT number of ventolin puffs} puffs every four hours Atrovent: {@INPUT Atrovent dosage in times per day} puffs a day Accolate: {@INPUT Accolate instructions} Zyflo: {@INPUT Zyflo instructions} Theophyllin: {@INPUT Theophyllin instructions} Prednisone: {@INPUT Prednisone instructions} }. The following medications are used in the red zone (60-80% best peak flow): {@INPUT medications used in red zone Beclomethasone (Beclovent or Vanceril): {@INPUT number of puffs of steroid spray} puffs {@INPUT number of times a day} a day Trimcinolone (Azmacort): {@INPUT number of steroid spray puffs} puffs {@INPUT number of times a day} a day Flunisolide (AereoBid): {@INPUT number of steroid puffs} puffs {@INPUT number of times a day} a day Fluticasone (Flovent): {@INPUT number of ug} ug {@INPUT number of times a day} a day Cromolyn (Intal): {@INPUT number of cromolyn puffs} puffs {@INPUT number of times a day} a day. Nedocromil (Tilade): {@INPUT number of tilade puffs} puffs {@INPUT number of times a day} a day. Ventolin: {@INPUT number of ventolin puffs} puffs every four hours Albuterol: {@INPUT number of albuterol puffs} puffs every four hours Maxair: {@INPUT number of maxair puffs} puffs every four hours Proventil: {@INPUT number of ventolin puffs} puffs every four hours Atrovent: {@INPUT Atrovent dosage in times per day} puffs a day Accolate: {@INPUT Accolate instructions} Zyflo: {@INPUT Zyflo instructions} Theophyllin: {@INPUT Theophyllin instructions} Prednisone: {@INPUT Prednisone instructions} }. Below 50% of your best peak flow indicates seeing a doctor or going to the emergency room immediately. Bbphigh/isolated elevated blood pressure found by nurseeThe blood pressure was found to be elevated. The patient was given a power point presentation that was consistent with guidelines. Handouts were provided that included: {@INPUT handouts blood pressure chart with recordings Mayo Oasis information on blood pressure control American Heart Association information on blood pressure life style changes the following: }. We will reconnect about how your blood pressure is after you have made several recordings. The best time chosen was around {@INPUTDATE Date you wish to connect} by {@INPUT how will you connect e-mail telephone return for consultation}.connoteConsult Notation{@INPUT Type of Consult} consultation by Dr. {@INPUT Input Consultant's last name} reviewed in detail. We appreciate {@INPUT Consultant's gender title @SINGLE his her } assistance. diabetes?diabetes assessment The following was done on {@LONGDATE} and indicates the patient's view on diabetes: You have clear and concrete goals for your diabetes care {@INPUT do you have clear goals for diabetes care: yes NO UNSURE NOTES {@INPUT notes} } You feel discouraged with your diabetes regimen {@INPUT Do you feel discouraged wieth your diabetes care: yes NO UNSURE NOTES {@INPUT notes} } You feel scared when you think about having and living with diabetes {@INPUT You feel scared when you think about having and living with diabetes : YES no UNSURE NOTES {@INPUT notes} } Are concerned that friends and relatives interrelate with you differently {@INPUT rAre concerned that friends and relatives interrelate with you differently: YES no UNSURE NOTES {@INPUT notes} } Feel deprived because of food and meal restrictions {@INPUT Feel deprived because of food and meal restrictions: YES no UNSURE NOTES {@INPUT notes} } Feel depressed about having diabetes {@INPUTFeel depressed about having diabetes: YES no UNSURE NOTES {@INPUT notes} } Wonder if moods are brought on by diabetes {@INPUT wonder if moods brought on by diabetes: YES no UNSURE NOTES {@INPUT notes} } Feel overwhelmed by your diabetes treatment {@INPUT Feel overwhelmed by your diabetes treatment: YES no UNSURE NOTES {@INPUT notes} } You are worrying about reactions {@INPUT ou are worrying about reactions: YES no UNSURE NOTES {@INPUT notes} } You are feeling angry about your diabetes {@INPUT You are feeling angry about your diabetes: YES no UNSURE NOTES {@INPUT notes} } Feeling your life is constantly being concerned about food and eating {@INPUTFeeling your life is constantly being concerned about food and eating: YES no UNSURE NOTES {@INPUT notes} } Worrying about future and complications of diabetes {@INPUTWorrying about future and complications of diabetes: YES no UNSURE NOTES {@INPUT notes} } Feeling guilty if your diabetes management gets off track {@INPUT Feeling guilty if your diabetes management gets off track: YES no UNSURE NOTES {@INPUT notes} } Do you accept your diabetes? {@INPUT Do you accept your diabetes?: yes NO UNSURE NOTES {@INPUT notes} } Feeling unhappy with your relationship with your physician and how diabetes is managed {@INPUT Feeling unhappy with your relationship with your physician and how diabetes is managed: YES no UNSURE NOTES {@INPUT notes} } Feeling that diabetes occupies to much of your time and energy {@INPUT Feeling that diabetes occupies to much of your time and energy YES no UNSURE NOTES {@INPUT notes} } Feel alone {@INPUT feel alone: YES no UNSURE NOTES {@INPUT notes} } Coping with your diabetes {@INPUT coping with diabetes: yes NO UNSURE NOTES {@INPUT notes} } Feeling burned out by diabetes {@INPUT burned outby diabetes: YES no UNSURE NOTES {@INPUT notes} } Have ideas for improving things {@INPUT Have ideas for improving things: YES no UNSURE NOTES {@INPUT notes} }D diabeteshpi diabetes HPIK#{@INPUT problem #} Diabetes mellitus {@INPUT Type of Diabetes @SINGLE NIDDM (Type 2) IDDM (Type 1)}, diagnosed in {@INPUT date of diagnosis} In reviewing the history, the patient is followed {@INPUT Who is following diabetes by a primary care physician by the diabetes clinic by primary care physician and diabetes clinic by the family medicine team by: {@INPUT doctors following} }. In the past year the patient has had the following diabetic visits: {@INPUT times seen in hospital with diabetes past year @SINGLE no one two three four five more then five } times in the hospital, {@INPUT times seen in ER with diabetes past year @SINGLE no one two three four five more then five } times in the ER and {@INPUT number of times seen in out patient setting for diabetes this past year} times as an outpatient. The patient {@INPUT diet is following an optimal diet is having difficulties following the diet is not following a diet would like further education on their diet has the following concerns about diet: {@INPUT diet notes} }. The monitoring of diabetes has been reviewed {@INPUT monitoring diabetes @SINGLE once a day twice a day three times a day four times a day once a week twice a week three times a week at no specific times at clinic visits notes {@INPUT notes on monitoring} }. The patient {@INPUT exercise pattern @SINGLE has no exercise program (210 MINUTES A WEEK IS EXCELLENT) is exercising 2 times a week (210 MINUTES A WEEK IS EXCELLENT) is exercising 3 times a week (210 MINUTES A WEEK IS EXCELLENT) is exercising 4 times a week (210 MINUTES A WEEK IS EXCELLENT) is exercising 5 times a week (210 MINUTES A WEEK IS EXCELLENT) is exercising 6 times a week (210 MINUTES A WEEK IS EXCELLENT) is exercising 7 times a week (210 MINUTES A WEEK IS EXCELLENT) and doing {@INPUT type of exercise} notes: {@INPUT notes in exercise} }. In reviewing complications of diabetes the following areas were reviewed: Diabetic acidosis: {@INPUT diabetes acidosis none notes: {@INPUT notes} } Hypoglycemia: {@INPUT hypoglycemia none notes: {@INPUT notes} } Eye complications: {@INPUT eye complications none cataracts retinopathy {@INPUT retinopathy description} fundi seen by eye clinic {@INPUT date of last eye exam} notes: {@INPUT notes} } Nephropathy complications: {@INPUT nephropathy none the last check for albumin in urine was in {@INPUT date of last albuminuria} is on ACE inhibitor notes: {@INPUT notes} } Neuropathy complications: {@INPUT neuropathy none notes: {@INPUT notes} } Myocardial complications: {@INPUT myocardial complications none the last treadmill was {@INPUT date of treadmill} notes: {@INPUT notes} } Atherosclerosis: {@INPUT atherosclerosis none notes: {@INPUT notes} } Other: {@INPUT other complications none obstetrical complications notes: {@INPUT notes} } The following prevention program has been set up and includes: {@INPUT prevention services one time Pneumovax yearly vaccination with Influenza foot care instruction preconception counseling one time Pneumovax, yearly vaccination with Influenza, and foot care instruction }. The patient's current medications are listed in the medication section of the medical record. The following data is included: {@INPUT other data to include none weight: {@INPUT weight} blood pressure: {@INPUT bp} fasting blood sugar: {@INPUT sugar value} HbA1C: {@INPUT HbA1C value} other: {@INPUT other data} } THE GOALS OF DIABETES CONTROL IS A BLOOD SUGAR PRIOR TO MEALS OF 80-120, A BEDTIME BLOOD SUGAR OF 120, AND A HbAC1 of 7 OR LESS WITHOUT SIGNIFICANT SYMPTOMS.dirxDirect Admission {@INPUT SELF ENTRY USERS: For patients transferred from other hospitals or facilities, who are medically unstable, those needing ICU beds or are being transported by Ambulance or helicopter, call the ER phone nurse at 5-5591 to preauthorize transportation as per EMTALA regulations. Do not create a Clinical Note) {@REM BE SURE YOU HAVE SELECTED "DIRADM" OR "EREVAL" AS THE SERVICE CODE IN CLINICAL NOTES. CHECK THIS BOX TO GO ON}}{@INPUT TRANSCRIPTIONISTS AND SELF ENTRY USERS: Ignore this field. Press Enter to go on. ER PHONE NURSE: Choose "Call Received From" and enter name and pager or phone number of caller on next screen @SINGLE {@REM Skip for transcriptionists and self entry users - will not print}{@DELETELINE} Call received from: {@REM ER Phone Nurses: Enter name and pager or phone number of caller on next screen}{@INPUT Enter name and pager or phone number of caller} } Referring Physician: {@INPUT Name, address, phone of referring provider} Summary of clinical history and reason for admission: {@INPUT Summarize clinical history and reason for transfer} Admitting diagnosis: {@INPUT Admitting diagnosis} Plan of care: {@INPUT Plan of care} Primary service requested: {@INPUT Enter primary service requested} {@INPUT Choose outpatient observation or inpatient admission @SINGLE Inpatient admission. Outpatient observation. } Type of admission: {@INPUT Choose type of admission @SINGLE Emergency Urgent Routine }. Room assignment needs: {@INPUT Room assignment needs (PLEASE NOTE: For patients transferred from other hospitals, who are medically unstable, those needing ICU beds or are being transported by Ambulance or helicopter, please call the ER phone nurse at 5-5591 to preauthorize transportation as per EMTALA regulations) ICU Private Strict Isolation Airbourne Isolation Monitored bed {@REM Other needs (IV drips, etc) - enter on next screen}{@INPUT list IV drips or other special needs} None }. Arrival date and time: {@INPUTDATE arrival date}, {@INPUT time of arrival} Mode of transportation: {@INPUT Mode of transportation (PLEASE NOTE: For patients transferred from other hospitals, who are medically unstable, those needing ICU beds or are being transported by Ambulance or helicopter, please call the ER phone nurse at 5-5591 to preauthorize transportation as per EMTALA regulations) @SINGLE Private car Ground ambulance Fixed wing Mayo One {@REM Other mode of transport - enter on next screen}{@INPUT Other mode of transport} }. Insurance Information: {@INPUT insurance information Unknown Medicare Private Insurance - {@REM Name of private insurance carrier - enter on next screen}{@INPUT Name of private insurance carrier} Medical Assistance - {@REM Name of medical assistance carrier - enter on next screen}{@INPUT Name of medical assistance insurance carrier} Managed Care - {@REM Name of managed care provider - enter on next screen}{@INPUT name of managed care insurance carrier} {@REM Name of other insurance carrier - enter on next screen}{@INPUT Name of other insurance carrier} }.ere ER Evaluationz{@INPUT SELF ENTRY USERS: For patients transferred from other hospitals or facilities, who are medically unstable, those needing ICU beds or are being transported by Ambulance or helicopter, call the ER phone nurse at 5-5591 to preauthorize transportation as per EMTALA regulations. Do not create a Clinical Note) {@REM BE SURE YOU HAVE SELECTED "DIRADM" OR "EREVAL" AS THE SERVICE CODE IN CLINICAL NOTES. CHECK THIS BOX TO GO ON}}{@INPUT TRANSCRIPTIONISTS AND SELF ENTRY USERS: Ignore this field. Press Enter to go on. ER PHONE NURSE: Choose "Call Received From" and enter name and pager or phone number of caller on next screen @SINGLE {@REM Skip for transcriptionists and self entry users - will not print}{@DELETELINE} Call received from: {@REM ER Phone Nurses: Enter name and pager or phone number of caller on next screen}{@INPUT Enter name and pager or phone number of caller} } Referring physician: {@INPUT Name, address, phone of referring provider} Brief summary of clinical history and reason for ER eval: {@INPUT Brief summary of clinical history and reason for ER eval} Diagnosis: {@INPUT Diagnosis} Special room needs: {@INPUT Special room needs (PLEASE NOTE: For patients transferred from other hospitals, who are medically unstable, those needing ICU beds or are being transported by Ambulance or helicopter, please call the ER phone nurse at 5-5591 to preauthorize transportation as per EMTALA regulations) @SINGLE None Strict Isolation Airbourne Isolation {@REM Other special needs, include IV drips - enter on next screen}{@INPUT other special needs, include IV drips} }. Arrival date and time: {@INPUTDATE Arrival date}, {@INPUT time of arrival} Mode of transportation: {@INPUT Mode of transportation (PLEASE NOTE: For patients transferred from other hospitals, who are medically unstable, those needing ICU beds or are being transported by Ambulance or helicopter, please call the ER phone nurse at 5-5591 to preauthorize transportation as per EMTALA regulations) @SINGLE Private car Ground ambulance Fixed wing Mayo One {@REM Other mode of transport - enter on next screen}{@INPUT Other mode of transport} }. facein Ace formularyZestril (lisinopril) {@INPUT dosage of Zestril 2.5 5 10 20 40 } mg daily {@INPUT number of pills} tabs with {@INPUT # of refills} refills.facidProton Pump Inhibitor{@INPUT Drugs proton inhibitors on formulary Protonix 40 mg one daily Aciphex 20 mg daily }, #{@INPUT number of pills needed} with {@INPUT # of refills} refills.fallergy antihistamineAllegra {@INPUT dosage 60 mg 180 mg } {@INPUT Number of times given daily twice daily } #{@INPUT number of pills of Allegra} with {@INPUT # of refills} refills.fantagformulary-H-2 AntagonistQIndications for H-2 Antagonist {@INPUT indication short term treatment of duodenal ulceration 150 mg BID or 300 in evening Maintenance therapy duodenal ulcer 150 mg in evening Short term maintenance of active benign gastric ulcer 150 mg BID Maintenance therapy of gastric ulcer 150 mg in evening Gastric hypersecretory condtions 150 mg twice daily GERD 150 mg twice daily Erosive esophagitis 150 mg four times a day Maintenance of healed erosive esophagitis 150 mg twice a day } Zantac (ranitidine) {@INPUT dosage of Zantac 150 mg tab 300 mg tab 150 mg efferdose granules 150 mg geldose 300 mg geldose Syrup (75m/tsp) } {@INPUT times a day of Zantac once a day once a day at bedtime twice a day } #{@INPUT number of pills needed} with {@INPUT refills 0 1 2 3 4 6 12 } refills The best time to take a single dose is 6 PMfbcp formulary-BCPM{@INPUT BCP Alesse Loestrin Fe 1/20 Loestrin Fe 1.5/30 LoOvral 28 Modicon Nordette 28 Ortho Novum 1:35 28 Ortho Novum 1:50 28 Ortho Novum 7-7-7 28 Orthocept Ortho-Cyclen 28 Ortho Tri-cyclen 28 Triphasil 28 } taken one daily {@INPUT number of packages 1 2 3 4 5 6 } with {@INPUT refills 0 1 2 3 4 } refillsfdeprSSRI{@INPUT Drugs SSRI Zoloft 50 mg daily Zoloft 100 mg daily Celexa 20 mg daily Celexa 40 mg daily Celexa 10 mg/5cc } #{@INPUT number of pills needed} with {@INPUT refills 0 1 2 3 4 5 6 } refills.fnoseSteroid nasal inhalersT{@INPUT Drugs nasal sprays Flonase Nasacort } {@INPUT Number of Squirts one squirt into each nostril daily two squirts daily into each nostril daily one squirt into each nostril twice daily two squirts into each nostril twice daily } #{@INPUT number of nasal inhalers needed} with {@INPUT refills 0 1 2 3 4 5 6 } refills.fnsaid)formulary nonsteroidal antiinflammatoriesJ{@INPUT NSAID naproxen 250 mg twice a day #{@INPUT number of pills} with {@INPUT refills} naproxen 375 mg twice a day #{@INPUT number of pills} with {@INPUT refills} naproxen 500 mg twice a day #{@INPUT number of pills} with {@INPUT refills} naproxen125mg/tsp twice a day {@INPUT number of tsp per dose} with {@INPUT refills} ibuprofen 200 mg every four hours #{@INPUT number of pills} with {@INPUT refills} ibuprofen 300 mg every four hours #{@INPUT number of pills} with {@INPUT refills} ibuprofen 400 mg every four hours #{@INPUT number of pills} with {@INPUTrefills} ibuprofen 600 mg every four hours #{@INPUT number of pills} with {@INPUT refills} ibuprofen 800 mg every six hours #{@INPUT number of pills} with {@INPUT refills} ibuprofen 100mg/tsp every four hours {@INPUT number of tsp per dose} with {@INPUT refills} }fstatinHMG Co-A ReductaseZocor (simvastatin) {@INPUT dosage of Zocor 5 10 20 40 } mg during evening #{@INPUT number of pills needed} with {@INPUT refills 0 1 2 3 4 6 12 } refills. hmhealth maintenancehealth maintenancehmcc"Health Maintenance Chief Complaint{@INPUT Input age of child} {@INPUT Select year/month/week year-old month-old week-old } here for a health maintenance visit.hmpe+Health Maintenance Physical Exam Components General: {@INPUT Enter age of child} {@INPUT Select year/month/week @SINGLE year-old month-old week-old day-old } who appears age appropriate. Skin: {@INPUT Skin exam @SINGLE Normal turgor and without lesions. {@REM Skin not normal}{@INPUT Skin problems} } Head: {@INPUT Head exam @SINGLE Normocephalic with age appropriate fontanelles Normocephalic {@INPUT Concerns about Head exam} }. Eyes: {@INPUT Eye exam @SINGLE Conjunctivae non-injected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. {@REM Eyes not normal}{@INPUT Eye problems} } {@INPUT Red reflex @SINGLE Red reflex present bilaterally. Symmetric light reflex. Red reflex present bilaterally. Symmetric light reflex, normal fundi. N/A{@DELETELINE} } ENT: {@INPUT ENT exam @SINGLE TMs gray, sharp landmarks, mobile, A.U. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally. {@REM ENT not normal}{@INPUT ENT problems} } Lymph Nodes: {@INPUT Lymph exam @SINGLE No significant lymphadenopathy. {@REM Lymph Nodes not normal}{@INPUT Lymph Nodes problems} } Thyroid: {@INPUT Thyroid exam @SINGLE No thyromegaly; trachea midline without masses. {@REM Thyroid not normal}{@INPUT Thyroid problems} } Breasts: {@INPUT Breast exam @SINGLE Without lesions or drainage. {@REM Breasts not normal}{@INPUT Breast problems} } Peripheral Vessels: {@INPUT Peripheral Vessel exam @SINGLE Normal pulses and perfusion. {@REM Peripheral Vessels not normal}{@INPUT Peripheral Vessel problems} } Heart: {@INPUT Heart exam @SINGLE Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. {@REM Heart not normal}{@INPUT Heart problems} } Lungs: {@INPUT Lung exam @SINGLE Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions. {@REM Lungs not normal}{@INPUT Lungs problems} } Abdomen: {@INPUT Abdomenal exam @SINGLE Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention. {@REM Abdomen not normal}{@INPUT Abdomenal problems} } Genitalia: {@INPUT Genitalia exam @SINGLE Normal male external genitalia; testes descended bilaterally; no hernia. Normal female external genitalia. {@REM Genitalia not normal}{@INPUT Genitalia problems} } Tanner: Tanner Stage {@INPUT Select Tanner Stage @SINGLE I II III IV V }. Spine: {@INPUT Spinal exam @SINGLE Straight with no lesions. {@REM Spine not normal}{@INPUT Spinal problems} } Joints: {@INPUT Joints exam @SINGLE Full range of motion about all joints. {@REM Joints not normal}{@INPUT Joint problems} } Extremities: {@INPUT Extremities exam @SINGLE No clubbing, cyanosis, or edema. Normal upper and lower extremities. {@REM Extremities not normal}{@INPUT Extremities problems} } Gait: {@INPUT Gait exam @SINGLE Normal and appropriate gait for age. {@REM Gait not normal}{@INPUT Gait problems} } Mental Status: {@INPUT Mental Status exam @SINGLE Alert, oriented, in no distress. Appropriate for age. {@INPUT Mental Status concerns} } Neuro: {@INPUT Neuro exam @SINGLE Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age. {@INPUT Neuro concerns} }hmvhealth maintenance visithealth maintenance visitHm1318"12-18 years prevention High school/ PREVENTION REVIEW This review was done when the youth was {@INPUT age 13 years old 14 years old 15 years old 16 years old 17 years old 18 years old } and given on {@LONGDATE} We have discussed the following life style topics that are important to know about as a teenager: {@INPUT topics of adolescence smoking habits alcohol use and being in a car with a driver who has been drinking recreational drugs sexual practices Testicular self examination(TSE) (TSE IS IMPORTANT TO DO ON A MONTHLY BASIS) anorexia } and answered questions. The following should be done yearly:height, weight, visual screening and blood pressure: {@INPUT vital signs done this year not done yet this year } Injury prevention is as follows: seatbelts: {@INPUT Seatbelts yes no-(PLEASE WEAR SEATBELTS) } Smoke detectors: {@INPUT Smoke detectors yes no (PLEASE INSTALL) } Bicycle or motorcycle helmet {@INPUT Bike helmets yes no (PLEASE WEAR HELMETS) does not bike } Guns and violence: {@INPUT guns and violence yes this was discussed and guns are locked yes this was discussed and GUNS SHOULD BE LOCKED yes and there are no guns in the home } Other risk factors reviewed: passive smoke: {@INPUT Smoke yes is at risk (We will help anyone in the family quit) not at risk } Exposure to tuberculosis: {@INPUT TB exposure includes close contacts, recent immigrants, migrant workers, exposure to homeless shelter yes-(you are at risk and need a TUBERCULIN TEST YEARLY tuberculin test done and should be repeated yearly) no exposure } Sunscreens: {@INPUT Sunscreens yes no-(you should WEAR SUNSCREENS 15 OR ABOVE) } Brushing teeth and dental care: {@INPUT dental yes, you see a dentist regularly no, you need to see a dentist } Exposure to loud noises: {@INPUT loud noises not exposed exposed and not wearing protection (PLEASE WEAR EAR PROTECTION) exposed and wearing protection } You have had a divorce in your family or separation, felt sad or are grieving: {@INPUT depression divorce grief no YES } You are angry or are frequently angry: {@INPUT are you angry or frequently angry no YES } You are of Caribbean, Latin American, Asian, Mediterranean, or African descent: {@INPUT sickle cell screening Carribean Latin American Asian African no not at risk for sickle cell anemia carrier yes at risk for sickle cell anemia carrier but had testing yes at risk for sickle cell anemia carrier and not had testing } Your shots are up to date: {@INPUT Shots yes no } and recorded in the past medical history. We recommend you learn CPR. REVIEW OF SYSTEMS:Gm1939prevention1939 Grown upf PREVENTION REVIEW This review was done when the adult was {@INPUT number of years} years old on {@LONGDATE}. We have discussed the following topics which are important issues in your age group:{@INPUT topics of age 19-39 cholesterol every five years (Your latest value is in the past medical history) smoking habits (Smoking history in PMH) alcohol use and being in a car with a driver who has been drinking (History in PMH) recreational drugs sexual practices (Concept of preconception counseling and high risk behavior) Testicular self examination(TSE) is recommended monthly Breast Self Exam (BSE) is recommended monthly. Family history of breast cancer. (Mammogram recommended based on age relative developed cancer and has been done {@INPUT mammogram date}) Previous mammogram {@INPUT mammogram date} Pap smear {@INPUT pap smear date} } and offered counseling. The following should be done yearly:height, weight, and blood pressure: {@INPUT vital signs done this year not done yet this year } Injury prevention is as follows: seatbelts: {@INPUT Seatbelts yes no-(PLEASE WEAR SEATBELTS) } Smoke detectors: {@INPUT Smoke detectors yes no (PLEASE INSTALL SMOKE DETECTORS) } Bicycle and motorcycle helmet {@INPUT Bike helmets yes no (PLEASE WEAR HELMETS) does not bike } Guns and violence: {@INPUT guns and violence yes this was discussed and no gun at home yes this was discussed and GUNS SHOULD BE LOCKED at home yes this was discussed and the guns are locked } Other risk factors reviewed: passive smoke: {@INPUT Smoke yes is at risk (We will help anyone in the family quit) not at risk } Exposure to tuberculosis: {@INPUT TB exposure includes close contacts, recent immigrants, migrant workers, exposure to homeless shelter yes-(you are at risk and need a TUBERCULIN TEST YEARLY tuberculin test done and should be repeated yearly) no exposure } Sunscreens: {@INPUT Sunscreens yes no-(YOU SHOULD WEAR SUNSCREENS 15 OR ABOVE) you have relatives with skin cancer or melanoma and should have skin checked regularly as well as sunscreens } Radiation to neck {@INPUT radiation to neck yes in past and YOU REQUIRE YEARLY THYROID EXAMS no } Have a family history of colon cancer, familial polyposis: {@INPUT colon cancer familial polyposis or colon cancer yes and received counseling (colonoscopy at certain age) no } Risk for back problems: {@INPUT back problems not at risk at risk and given instructions } Brushing teeth and dental care: {@INPUT dental yes no (Work on dental care) } Exposure to loud noises: {@INPUT loud noises not exposed exposed and not wearing protection (PLEASE WEAR EAR PROTECTION) exposed and wearing protection } You have had a divorce in your family or separation, felt sad or are grieving: {@INPUT depression divorce grief no YES } You are angry or are frequently angry: {@INPUT are you angry or frequently angry no YES } You are of Caribbean, Latin American, Asian, Mediterranean, or African descent: {@INPUT sickle cell screening Carribean Latin American Asian African no not at risk for sickle cell anemia carrier yes at risk for sickle cell anemia carrier but had testing yes at risk for sickle cell anemia carrier and not had testing } Your shots are up to date: {@INPUT Shots yes no } The shot record is located in the past medical history. We recommend all families to know CPR. REVIEW OF SYSTEMS:Tm26 prevention 2 - 6 year old todler PREVENTION REVIEW This review was done when the child was {@INPUT age @SINGLE 2 years old 3 years old 4 years old 5 years old 6 years old } on {@LONGDATE}. The following should be done yearly: height, weight, visual screening and blood pressure, {@INPUT vital signs @SINGLE done this year not done yet this year } Injury prevention is as follows: Seatbelts: {@INPUT Seatbelts @SINGLE yes no-(PLEASE WEAR RESTRAINTS IN CAR) } Smoke detectors: {@INPUT Smoke detectors @SINGLE yes no (PLEASE INSTALL SMOKE DETECTORS) } Hot water temperature: {@INPUT Hot water @SINGLE yes no (PLEASE HAVE TEMPERATURE OF WATER SET AT 120 DEGREES) } Bicycle helmet: {@INPUT Bike helmets @SINGLE yes no (PLEASE WEAR BIKE HELMET) does not ride bike } Storage of drugs, guns, matches and chemicals: {@INPUT drugs guns matches and chemicals @SINGLE yes no (PLEASE MAKE SURE HOME SAFE FOR STORING GUNS, MATCHES, CHEMICALS, AND DRUGS) } Syrup of ipecac and poison control number which is 1-800-222-1222 {@INPUT Poisons @SINGLE yes no (Please check) } Other risk factors reviewed: Passive smoke: {@INPUT Smoke @SINGLE not at risk yes is at risk (We will help anyone in the family quit) } Exposure to lead (exposed to house older than 1950, occupation involving lead, or near a hazardous waste area): {@INPUT exposed to house older than 1950, occupation, hazardous area @SINGLE not at risk screening done to be sure no risk yes-your child is at risk for lead ingestion and needs screening } Exposure to tuberculosis: {@INPUT TB exposure includes close contacts, recent immigrants, migrant workers, exposure to homeless shelter @SINGLE no exposure tuberculin test done and should be repeated yearly yes-(YOU ARE AT RISK FOR TB AND NEED A TUBERCULIN TEST YEARLY) } Hearing loss risk: {@INPUT Hearing loss-Serious childhood infections, birth weight below 1500 gm, meningitis, low Apgar score of 0-3 @SINGLE no risk yes your child is at risk for hearing loss and should be checked yearly } Sunscreens: {@INPUT Sunscreens @SINGLE yes no-(YOU SHOULD HAVE CHILD WEAR SUNSCREENS 15 OR ABOVE) } Fluoride candidate: {@INPUT Fluoride @SINGLE yes-discuss usage not needed } Brushing teeth and dental care: {@INPUT dental @SINGLE yes no (DENTAL CARE EMPHASIZED) } Family member knows CPR: {@INPUT CPR in family @SINGLE yes no (Training is available in the community) } Your immunizations are up to date: {@INPUT immunizations up-to-date? @SINGLE yes no } and can be found in our central immunization center. REVIEW OF SYSTEMS:Wm4064prevention 40-64 Working harderPREVENTION REVIEW This review was done when the adult was {@INPUT number of years} years old on {@LONGDATE}. We have discussed the following topics which are important for all people in your age group:{@INPUT topics of age 40-64 cholesterols every five years (see past medical history for your value) smoking habits (can be found in past medical history) alcohol use, abstinence, and being in a car with a driver who has been drinking recreational drugs aspirin should be taken daily sexual practices Testicular self examination(TSE) is recommended monthly Prostate check yearly:last exam {@INPUT date of prostate exam or refused} PSA checked yearly if over 40 and is black or has family history otherwise starting at 50-last check {@INPUT year of PSA and Value or refused} Breast self exam (BSE) is recommended monthly Family history of breast cancer Mammograms recommended yearly Mammograms recommended every other year until 50 then every year Last mammogram was done {@INPUT mammogram date} Pap smear was done {@INPUT pap smear date} Hormone replacement therapy } and offered counseling. The following should be done yearly:height, weight, and blood pressure: {@INPUT vital signs done this year not done yet this year } Injury prevention is as follows: seatbelts: {@INPUT Seatbelts yes no-(PLEASE WEAR SEATBELTS) } Smoke detectors: {@INPUT Smoke detectors yes no (PLEASE INSTALL SMOKE DETECTORS) } Bicycle and motorcyle helmet {@INPUT Bike helmets yes no (PLEASE WEAR HELMETS) does not bike } Guns and violence: {@INPUT guns and violence yes this was discussed and guns in the house are locked yes this was discussed and GUNS SHOULD BE LOCKED at home no gun in home } Other risk factors reviewed: passive smoke: {@INPUT Smoke yes is at risk (We will help anyone in the family quit) not at risk } Exposure to tuberculosis: {@INPUT TB exposure includes close contacts, recent immigrants, migrant workers, exposure to homeless shelter yes-(you are at risk and need a TUBERCULIN TEST YEARLY tuberculin test done and should be repeated yearly) no exposure } Sunscreens: {@INPUT Sunscreens yes no-(you should WEAR SUNSCREENS 15 OR ABOVE) you have relatives with skin cancer or melanoma and should have skin checked regularly as well as sunscreens } Radiation to neck {@INPUT radiation to neck yes in past and YOU REQUIRE YEARLY EXAMS OF THYROID no } Have a family history of colon cancer, familial polyposis: {@INPUT colon cancer familial polyposis or colon cancer yes and received counseling (colonoscopy at certain age) no } Proctoscopic examination recommended after age 50 {@INPUT proctos not 50 yet and no history for doing this earlier refused proctoscopic examination {@INPUT procto examination date} barium enema {@INPUT barium enema date} colonoscopy {@INPUT colonoscopy date} } Risk for back problems: {@INPUT back problems not at risk at risk and given instructions } Brushing teeth and dental care: {@INPUT dental yes no (Work on dental care) } Exposure to loud noises: {@INPUT loud noises not exposed exposed and not wearing protection (PLEASE WEAR EAR PROTECTION) exposed and wearing protection } You are at risk for diabetes: {@INPUT diabetes risk no risk previous gestational diabetes overweight strong family history of diabetes and has had diabetes checked for in past year } Your risk for cancer is related to these relatives: {@INPUT family members with cancer}. You have had a divorce in your family or separation, felt sad or are grieving: {@INPUT depression divorce grief no YES } You are angry or are frequently angry: {@INPUT are you angry or frequently angry no YES } Your shots are up to date: {@INPUT Shots yes no } and can be found in past medical history. We recommend all families know CPR. REVIEW OF SYSTEMS: Rm65'prevention of patient over 65 (Retired)g PREVENTION REVIEW This review was done when the adult was {@INPUT number of years} years old on {@LONGDATE}. We have reviewed the following topics:{@INPUT topics of age 65 and over smoking habits (See past medical history) alcohol use and being in a car with a driver who has been drinking(See past medical history) symptoms of transient ischemic attack ASPIRIN DAILY if 2 risk factors for heart disease sexual practices hot water temperature is set at 120 degrees Testicular self examination (TSE) is recommended monthly and prostate examination and PSA is recommended yearly prostate check refused prostate check in {@INPUT year prostate check} PSA refused PSA value was {@INPUT value and year of PSA} Breast Self Exam (BSE) is recommended monthly Mammogram recommended yearly {@INPUT Mammogram last date} Pap smear {@INPUT Pap smear last date} Hormone replacement therapy is recommended } and offered counseling. The following should be done yearly:height, weight, visual acuity, hearing test and blood pressure: {@INPUT vital signs done this year not done yet this year } Injury prevention is as follows: seatbelts: {@INPUT Seatbelts yes no-(PLEASE WEAR SEATBELTS) } Smoke detectors: {@INPUT Smoke detectors yes no (PLEASE INSTALL SMOKE DETECTORS) } Bicycle helmet {@INPUT Bike helmets yes no (PLEASE RIDE WITH HELMETS) does not ride a bike } Guns and violence: {@INPUT guns and violence yes this was discussed and guns are locked yes this was discussed and GUNS SHOULD BE LOCKED UP no guns are in the home } Other risk factors reviewed: Exposure to tuberculosis: {@INPUT TB exposure includes close contacts, recent immigrants, migrant workers, exposure to homeless shelter yes-(YOU ARE AT RISK AND NEED A TUBERCULIN TEST YEARLY tuberculin test done and should be repeated yearly) no exposure } Sunscreens: {@INPUT Sunscreens yes no-(you should wear SUNSCREENS 15 OR HIGHER) you have relatives with skin cancer or melanoma and should have skin checked regularly as well as sunscreens } Radiation to neck {@INPUT radiation to neck yes in past and YOU REQUIRE YEARLY EXAMS OF YOUR THYROID no } A flexible sigmoidoscopy is recommended every three to five years. You have{@INPUT colon cancer evaluation decided not to get an examination at this time received a proctoscopic examination in {@INPUT date of procto} received barium enema in {@INPUT barium enema date} received colonoscopy in {@INPUT colonoscopy date} } Risk for falls: {@INPUT falls not at risk AT RISK FOR FALLS and given instructions } Brushing teeth and dental care: {@INPUT dental yes no (Work on teeth) } You last saw the eye doctor in {@INPUT date saw eye doctor} You are at risk for diabetes: {@INPUT diabetes risk no risk previous gestational diabetes overweight strong family history of diabetes and has had diabetes checked for in past year } Your risk for cancer is related to these relatives: {@INPUT family members with cancer}. You have had a divorce in your family or separation, felt sad or are grieving: {@INPUT depression divorce grief no YES } You are angry or are frequently angry: {@INPUT are you angry or frequently angry no YES } Your shots are up to date: {@INPUT Shots yes no }. Your shots are recorded in the past medical history. WE ENCOURAGE FAMILIES TO KNOW CPR. CLASSES ARE AVAILABLE THROUGH COMMUNITY EDUCATION. REVIEW OF SYSTEMS:Em712%prevention of 7-12 year old-ElementryaPREVENTION REVIEW This review was done when the child was {@INPUT age 7 years old 8 years old 9 years old 10 years old 11 years old 12 years old } on {@LONGDATE}. The following should be done yearly:height, weight, visual screening and blood pressure: {@INPUT vital signs done this year not done yet this year } Injury prevention is as follows: seatbelts: {@INPUT Seatbelts yes no-(PLEASE WEAR CAR RESTRAINTS) } Smoke detectors: {@INPUT Smoke detectors yes no (PLEASE INSTALL SMOKE DETECTORS) } Bicycle helmet {@INPUT Bike helmets yes no (PLEASE WEAR HELMETS WHEN BIKING) } Storage of drugs, guns, matches and chemicals: {@INPUT drugs guns matches and chemicals yes no (PLEASE PROVIDE SAFETY) } The poison control number which is 1-800-222-1222. Other risk factors reviewed: passive smoke: {@INPUT Smoke yes is at risk (We will help anyone in the family quit) not at risk } Exposure to tuberculosis: {@INPUT TB exposure includes close contacts, recent immigrants, migrant workers, exposure to homeless shelter yes-(you are at risk and need a tuberculin test yearly tuberculin test done and should be repeated yearly) no exposure } Sunscreens: {@INPUT Sunscreens yes no-(WEAR SUNSCREENS 15 OR ABOVE) } Flouride candidate: {@INPUT Flouride yes-you should make sure to use flouride not needed } Brushing teeth and dental care: {@INPUT dental yes no (WORK ON DENTAL CHECKUPS) } Your shots are up today: {@INPUT Shots yes no }. The shots are found in our central computer base. We suggest the family is trained in CPR. Classes are available in the community REVIEW OF SYSTEMS:mccChief ComplaintCThe patient has the following goals for this visit {@INPUT goals}.mcfmayo clinic formulary,The patient is on the Mayo Clinic FormularyE@memailemail shortcutThe following are your results: {@INPUT Results hemoglobin was normal with a value of {@INPUT hemoglobin value} The rest of your cells were normal studies for diabetes liver and kidney diseases were normal cholesterol was {@INPUT cholesterol} with a good cholesterol (HDL) of {@INPUT HDL} plus a LDL the bad cholesterol of {@INPUT LDL} I like to see the LDL below 160 in low risk patients and 130 in moderate risk patients and 100 in people who have had heart disease pap smear was normal mammogram was normal PSA or check for prostate cancer was normal chest x-ray was normal electrocardiogram was normal echocardiogram was normal hearing tests thyroid was normal cultures showed no problems procto/colonoscopy was normal breathing tests were normal}. In summary all looks well! There is a wonderful website at http://www.wellmed.com You may wish to look at doing their personal profile and develop your own personal medical record on the net.. F@mfamilytemplate for family historyKids: {@INPUT kids none {@INPUT Kids names ages illnesses and location} } Siblings: Brothers: {@INPUT number of brothers none one two three four five more then five} and Sisters: {@INPUT number of sisters none one two three four five more then five}. The following illnesses and deaths are recorded: {@INPUT siblings illnesses and deaths} Parents: Father {@INPUT illness death and location of father is all healthy and lives in {@INPUT location} has the following illness {@INPUT illness of father} and lives in {@INPUT location} has died and had the following illnesses: {@INPUT illness and death cause} is adapted no knowledge of father's illness }. Mother {@INPUT illness death and location of mother is all healthy and lives in {@INPUT location} has the following illness: {@INPUT illnesses of mother} and lives in {@INPUT location} has died and had the following illnesses: {@INPUT illnesses and death and cause} is adapted no knowledge of mother's illness }. Grandparents: {@INPUT grandparents have no significant illnesses have the following illnesses: {@INPUT grandparent illnesses} died and had the following illnesses: {@INPUT grandparent llnesses} }. Spouse: {@INPUT spouses name} and is {@INPUT marriage status married in {@INPUT year of marriage} divorced {@INPUT Year of divorce} widowed {@INPUT Year widowed} never had a spouse } and has the following illnesses: {@INPUT Spouses illness none {@INPUT spouses illnesses} died from {@INPUT spouses death} } Other: mgoalGoals for the patientBlood pressure of 140/90 or less Blood pressure of 135/85 or less Cholesterol LDL level of 160 or less Cholesterol LDL level of 130 or less Cholesterol LDL level of 100 or less Weight of {@INPUT Weight in pounds goal} Tobacco cessation Alcohol cessation Exercise of 210 minutes a week Calcium four servings a day (1200 mg) Seatbelt use when in car Decrease workload in life Mammography every year Colon evaluation every 5 years H@mhpihpi:#1 Health Care Maintenance Goals: #2 Acute illness-nonemhypervThe patient was found to have an elevated blood pressure on this examination. The patient has {@INPUT what did you do about hypertension had normal values at home ranging from {@INPUT BPs at home} had instructions given to have the blood pressure rechecked and confirm that it is below {@INPUT BP Goal} has received powerpoint presentation and materials per protocol }miiidenifying informationThis patient would like to be called {@INPUT name} and would like to be called at the following number Work {@INPUT work phone}: or Home {@INPUT home phone}{@INPUT accompany Patient is in office by self Patient is accompanied by }. They have an e-mail at {@INPUT e-mail}.Mmmenopmenopause gyn historyBMenstrual History:G (How many times you have been pregnant) {@INPUT G 0 1 2 3 4 5 6 7 8 9 more then nine times } P (How many deliveries you have had) {@INPUT P 0 1 2 3 4 5 6 7 8 9 more then 9 } You have had the following reproductive events: {@INPUT reproductive complications no complications related to reproduction {@INPUT number of c sections} C-sections {@INPUT number of miscarriages} miscarriages {@INPUT number of abortions} abortions {@INPUT number of c sections} ectopic pregnancy or tubal pregnancy } LMP {@INPUT last menstrual period}. Abnormal paps in the past: {@INPUT abnormal pap is too young for a pap smear has never been found has been found in the past has been found and requires scheduling more exams then usual }. Contraception: {@INPUT contraception none required none used none used and trying to become pregnant. Preconception counseling given. currently using but planning to become pregnant. Preconception counseling given birth control pills vasectomy tubal ligation condoms foam diapragm depoprovera IUD natural family planning } DES exposure {@INPUT DES exposure has happened is not a factor in history }. Hormone replacement therapy discussed and is {@INPUT hormone replacement therapy is being used is not being used and has been discussed at this visit }mmensesmenstrual gyn history&Menstrual History:G (How many times you have been pregnant) {@INPUT G 0 1 2 3 4 5 6 7 8 9 more then nine times } P (How many deliveries you have had) {@INPUT P 0 1 2 3 4 5 6 7 8 9 more then 9 } You have had the following reproductive events:{@INPUT reproductive complications no complications related to reproduction {@INPUT number of c sections} C-sections {@INPUT number of miscarriages} miscarriages {@INPUT number of abortions} abortions {@INPUT number of c sections} ectopic pregnancy or tubal pregnancy } LMP {@INPUT LMP} Periods are {@INPUT period are about every 3 weeks every 4 weeks every 5 weeks every 6 weeks every 8 weeks every 3 months every six months are irregular {@INPUT define irregular periods} are absent } with a flow lasting {@INPUT flow length less then two days two to four days four to five days six to seven days ten days two weeks no flow }. Associated cramps: {@INPUT cramps are not present are present but not requiring medication are present and require medication } On a scale of 1-10 with 1 being very scant and 10 being very heavy, how heavy are your periods {@INPUT heavy period no period 1 2 3 4 5 6 7 8 9 10 }. Abnormal paps in the past: {@INPUT abnormal pap is too young for a pap smear has never been found has been found in the past has been found and requires scheduling more exams then usual }. Contraception: {@INPUT contraception none required none used none used and trying to become pregnant. Preconception counseling given. currently using but planning to become pregnant. Preconception counseling given birth control pills vasectomy tubal ligation condoms foam diapragm depoprovera IUD natural family planning } DES exposure {@INPUT DES exposure has happened is not a factor in history }.mminimentalstatemental status assessment-The patient orientation knew the date, year, season, month and day for five points. The patient knew what state, county, town and hospital we were located at for five points. The patient could repeat the names of three objects in the room for three points. The patient could spell world backwards for five points. The patient then could recall the three objects in the room that had been idenified before for three points. The patient could then idenify two objects I pointed to for two points, repeated No ifs ands, or buts for one point, was able to take a sheet of paper fold it in half and put it on the floor for three points, was able to close their eyes on command for one point, write a sentence for one point, and draw the face of a watch for three points. The total score for the mini-mental state was mpain pain history2Pain began {@INPUT pain started and what doing?}. Locataion: {@INPUT where located} and radiates to {@INPUT radiates}. Pain worstens with {@INPUT what makes worst} and improves with {@INPUT what makes better}. Medications tried: {@INPUT meds taken} Associated symptoms: {@INPUT Associated symptoms}mpmh pmh templateHospitalizations: {@INPUT Hospitalizations none {@INPUT type of hospitalization and date} } Trauma: {@INPUT Trauma none {@INPUT type of bone and year} } Significant Illnesses: {@INPUT Significant illness none {@INPUT type of illnesses} } Significant events past year: {@INPUT Significant Events past year none events: {@INPUT Types of events} } Immunizations: DT {@INPUT DT Last DT was {@INPUT year} Given in 2000 Reaction precludes giving } MMR {@INPUT mmr yes in the following year {@INPUT mmr} given in 2000 had illness } Pneumovax {@INPUT pneumovax indications is indicated because of a lung or heart condition is indicated because of being age 65 or older is indicated because of an absent spleen is indicated because of being immunosuppressed because of medication or disease is not indicated is not wanted and was given in {@INPUT date of pneumovax} }. Influenza {@INPUT influenza indications is indicated because of a lung or heart condition is indicated because of being age 65 or older is indicated because of an absent spleen is indicated because of being immunosuppressed because of drug or disease because of being a health care provider or high risk exposure is wanted for prevention of illness is not indicated is not wanted was given in {@INPUT date of influenza} and recommended every October } Chicken Pox {@INPUT chicken pox yes {@INPUT Chicken pox vaccine date} no and is immune because they had the disease not wanting immunization } Hepatitis B series is recommended for all babies, anyone exposed to blood products, or people who may have hepatitis B {@INPUT hepatitis B series administered and completed {@INPUT hepatitis B series completed date} series is currently given not a candidate not wanting series } Cholesterol Total Cholesterol/HDL/LDL:{@INPUT Total cholesterol value}/{@INPUT HDL value}/{@INPUT LDL value} done in {@INPUT year lipids checked}. OUR RECOMMENDATIONS ARE THEY SHOULD BE CHECKED EVERY {@INPUT time to check cholesterol 3 months because you are on medication 6 months because you are on medication one year because we are watching it closely five years because it is normal } years.mresul my resultsttoday i am going to give you your results The results are {@INPUT results pap smear CBC x-ray } Have a nice dayLmresult+The results for giving studies to a patient^The following studies will be done for you {@INPUT tests no tests blood work (ERIS) pap smear x-rays mammogram procto/colonoscopy urine ECG hearing tests cultures breathing tests biopsies consultations {@INPUT consultations} } The results will be given to you by {@INPUT results given by receiving this note calling into labtalk e-mailing you {@INPUT e-mail address} calling you directly by one of the nurses The results will be given to you on {@INPUTDATE results given} through guest house providers having you return for results having the consultant inform you of the results }.L@mresultsresults set up for John BachmanThe following studies will be done for you {@INPUT tests no tests blood work (ERIS) pap smear x-rays mammogram procto/colonoscopy urine ECG hearing tests cultures breathing tests biopsies consultations {@INPUT consultations} } The results will be given to you by {@INPUT results given by receiving this note calling into labtalk e-mailing you {@INPUT e-mail address} Mayo E-mail E-mail by address given to nurse calling you directly by one of the nurses The results will be given to you on {@INPUTDATE results given} having you receive a letter through guest house providers having you return for results having the consultant inform you of the results }. A copy of your note is provided which lists the details of your patient visit. If you find any errors leave a voice mail message with one of our nurses. If you use e-mail remember that e-mail is like sending a post card. My e-mail address is bachman.john@mayo.edu, my secretary (Jackie) has a phone number of 284-2774. Our office appointments is 284-5300, and Michelle is 284-3825 and her e-mail address is enos.michelle@mayo.edu. Our triage nurse is at 284-2735(Most often Jill) To have your prescriptions refilled in the future have your pharmacy fax us at 266-0510 (You may fax us too!). To check on appointments or follow-up tests call our receptionist at 284-1763. We are a team dedicated to helping you get the best health care.F mshfemalesocial history femaleWorks as a {@INPUT works as a} doing {@INPUT hours of work no hours because of retirement no hours because of unemployment no hours because of disability less then 10 hours a week 20 hours a week 32 hours a week 40 hours a week 50 hours a week 60 hours a week more then 60 hours a week }. Smoke: {@INPUT smoking yes WE WILL HELP YOU QUIT SMOKING! never quit in {@INPUT Year quit smoking and the number of pack years} packs/years } ETOH: {@INPUT ETOH: yes Cage administered and was negative and showed you felt need to cut down drinking and showed you felt someone wanted you to cut down and showed you felt guilty about drinking and showed you felt like I need an eye opener not consuming alcohol }. Caffeine: {@INPUT Caffeine: yes no 1-2 caffeine servings 2-4 caffeine servings 4-6 caffeine servings 6-8 caffeine servings (YOU MAY WISH TO MODERATE YOUR CAFFEINE USE) over 9 caffeine servings (YOU MAY WISH TO MODERATE YOUR CAFFEINE USE) over 15 caffeine servings (YOU MAY WISH TO MODERATE YOUR CAFFEINE USE) over 20 caffeine servings (YOU MAY WISH TO MODERATE YOUR CAFFEINE USE) } Calcium: {@INPUT Calcium: no servings (YOU NEED TO INCREASE YOUR CALCIUM to four servings a day one tum=one serving one serving a day (YOU NEED TO INCREASE YOUR CALCIUM to four servings a day one tum=one serving) two servings a day (YOU NEED TO INCREASE YOUR CALCIUM to four servings a day one tum=one serving) three servings a day (YOU NEED TO INCREASE YOUR CALCIUM To four servings a day one tum=one serving) four servings a day more then four servings a day you are on a diet which restricts calcium use }. Exercise: {@INPUT Exercise none (YOU WOULD BENEFIT FROM A REGULAR EXERCISE PROGRAM RECOMMENDATIONS ARE 210 MINUTES A WEEK) some RECOMMENDATIONS ARE 210 MINUTES A WEEK) regular program RECOMMENDATIONS ARE 210 MINUTES A WEEK) }. Church: {@INPUT church} Hobbies: {@INPUT hobbies} Organ donor: {@INPUTorgan donor yes no and not interested in becoming a donor interested in becoming a donor and information provided } Living will: {@INPUTliving will yes not done yet } Safe: {@INPUT safe yes no } Wheel of Violence: This is given to you to reflect on power and control.Mmshmalesocial history of maleoWorks {@INPUT Number of hours is retired is disabled is unemployed 0-10 hours a week 10-20 hours a week 20-30 hours a week 30-40 hours a week 40-50 hours a week 50-60 hours a week over 60 hours } as a {@INPUT Type of work} smoke: {@INPUT Smoking yes and have a history of {@INPUT number of pack years} of smoking. WE WILL HELP YOU QUIT. quit and have a history of {@INPUT number of pack years} of smoking no have never smoked }. Alcohol use: {@INPUT ETOH: yes and CAGE was administered and results were: negative positive you felt a need to cut down drinking positive someone thinks you need to cut down drinking positive you felt guilty about drinking positive you felt you need an eye opener does not drink alcohol }. Caffeine:{@INPUTCaffeine: yes no 0-2 servings of caffeine a day 2-4 servings of caffeine a day 4-6 servings of caffeine a day (YOU NEED TO MODERATE YOUR CAFFEINE USE) 7-10 servings of caffeine a day (YOU NEED TO MODERATE YOUR CAFFEINE USE) more then ten servings a day (YOU NEED TO MODERATE YOUR CAFFEINE USE) more then twenty servings a day (YOU NEED TO MODERATE YOUR CAFFEINE USE) } Exercise: {@INPUT Exercise none (YOU NEED TO EXERCISE MORE-RECOMMENDATIONS ARE 210 MINUTES PER WEEK) some (RECOMMENDATIONS ARE 210 MINUTES A WEEK) regular exercise program (RECOMMENDATIONS ARE 210 MINUTES A WEEK)}. Church: {@INPUT Church type} Hobbies: {@INPUT hobbies}. Organ donor: {@INPUTorgan donor yes not interested in becoming donor interested in becoming a donor and information provided } Living will: {@INPUT living will: yes not completed yet } SAFE: {@INPUT safe: yes no }.mshotOn {@SHORTDATE} the following was given: {@INPUT shots at mayo DT Pneumovax Influenza HBV-HIB HBV DTaP DTaP-HIB IPV OPV PCV7 (Pneumococcal Vaccine) MMR Varivax Meningococcal Vaccine }msignurses signatureThe nurse phone numbers is Michelle: 284-3825. If you have prescripiton refills you can call your pharmacy and they will fax us your prescription. Currently our e-mail address for Dr. B. is bachman.john@mayo.edu {@INPUT Your signature}Umuri uri historyThis illness started {@INPUT When did illness start one day ago two days ago three days ago four days ago five days ago about a week ago about ten days about two weeks ago over two weeks ago }. Rhinitis {@INPUT Rhinitis is present is not present }. A cough {@INPUT cough is not present is present, and it is productive and discolored is present and productive and clear is present and nonproductive }. Ear pain {@INPUT ear pain is present is not present is not able to be evaluated }. A sore throat {@INPUT sore throat is present is not present is not able to be evaluated }. A fever {@INPUT fever has been present during the illness. is not present. } There {@INPUT appetite has been a loss of appetite. has not been a loss of appetite. There has been vomiting or diarrhea. } The following medications were tried:{@INPUT what medications tried}. A vaporizer is {@INPUT vaporizer being used not being used }. {@INPUT family members No other family members have been ill Other family members have the following illnesses {@INPUT What illnesses are in family} }. Smoking: {@INPUT smoking is a current habit is not a factor in this illness is present in the family }. nextvisitNext visit preparationdThe next visit should be {@INPUT When do you want patient to return}. The following tests can be prescheduled : {@INPUT Studies you want CBC Cholesterol Lipid Profile Prothrombin Time Potassium Creatinine SGOT Blood Sugar HbA1C mammogram procto/colonoscopy urine ECG hearing tests Chest X-ray breathing tests and {@INPUT Other tests} }.nmcfNot Mayo Clinic Formulary Not using Mayo Clinic Formularynobp1There is no BP on this patient because {@INPUT Why no BP The patient is here for results only and was normaltensive The patient is a guest house patient and has regular BPs at home The patient has regular BPs done at an institution The patient is at an age where it needs to be checked yearly only }Pobnunursing prenatal visitDYour visit is on {@INPUTDATE Todays date}. Your doctor is Doctor Bachman. Your weight was {@INPUT weight} This makes a weight gain of {@INPUT pounds gained} from your last visit and a total weight gain of {@INPUT weight gain since first visit} Your BP today is {@INPUT BP Reading}. We estimate that you are {@INPUT gestational age} weeks. You have {@INPUT Baby movement felt the baby moving not felt the baby moving }. You have experienced {@INPUT contractions contractions no evidence of contractions }. Education was given by powerpoint {@INPUT powerpoint yes no }. pcoldPhysical for a cold or URIEARS: Examination of {@INPUT Affected side right ear left ear both ears} reveals {@INPUT(ears) ear abnormalities normal findings reddened canal swelling cerumen impaction erythematous TM perforated TM bulging TM discharge Weber tuning fork test lateralizes to this side air conduction is greater than bone conduction bone conduction is greater than air conduction }. NOSE: Nose examination reveals {@INPUT(nose) nose abnormalities normal findings epistaxis rhinorrhea purulent discharge sinus tenderness deviated nasal septum }. ORAL CAVITY AND PHARYNX: Oral cavity and pharynx {@INPUT(throat) mouth and throat abnormalities normal tonsillar inflammation tonsillar exudate pharyngeal inflammation accumulation of mucous teething teeth in poor general condition absent teeth TMJ tenderness }. LUNGS: Auscultation of the lungs revealed {@INPUT lung findings clear rhonchi rales wheezing diminished breath sounds tachypnea labored breathing }. Vpedvssize percentagesThe height % was{@INPUT height}, the weight % was {@INPUT weight} and {@INPUT head size the head size % was {@INPUT head size} no other percentiles were checked }puti UTI screeningFemale UTI Telephone Triage Form Patient's age {@INPUT patient's age} Patient complains of {@INPUT complains of dysuria frequency urgency other symptoms including {@INPUT(othersymptoms) other symptoms including} } The patient does not complain of {@INPUT(symptoms) does not complain of symptoms > 7 days duration shaking chills flank pain temp > 101 nausea vomiting abdominal pain change in vaginal discharge or odor painful intercourse } The patient has no history of {@INPUT(history) no history of pyelonephritis within the last 3 months diabetes pregnancy, LMP {@INPUT(LMP) LMP} immunosuppression kidney stones kidney failure catheterization within the last 2 weeks hospitalization/nursing home residency within the last 2 weeks 4 or more UTI's within the last 12 months failure of antibiotic failure for a UTI in the last 4 weeks. } The patient {@INPUT(outcomes) The patient failed the UTI protocol due to {@INPUT(failures) failed the UTI protocol due to} has an uncomplicated UTI. } Medication allergies: {@INPUT medication allergies:} The patient was {@INPUT(treatment) The patient was referred to a physician/nurse practitioner. treated with Trimethoprim/Sulfamethoxazole DS 1 BID x 3 days. treated with Trimethoprim 100 mg 1 BID x 3 days. treated with Macrodantin 100 mg BID x 7 days. treated with Ciprofloxacin 250 mg BID x 3 days. treated with {@INPUT(othermedications) treated with} } Nurse's name: {@INPUT(nursesname) nurses name}TrxtraumaTreatment of traumaThe treatment for your injury is to use ice 20 minutes {@INPUT ice one two three four } times a day. You should rest the area so it has a chance to heal. For pain you should use the following:{@INPUT meds used tylenol or equivalent aspirin or equivalent ibuprofen alleve }. You should expect improvement after {@INPUT time to get better one two three four } days. If things get worst instead of improving contact us.Urxuri uri treatment~Rest or take it easy. Drink plenty of fluids. The following might be helpful {@INPUT medications for URI acetaminophen (tylenol) for fever and aches ibuprofen for fever and aches lozenges throat sprays cough medicines over the counter such as {@INPUT cough medication} }. A vaporizer and turning the shower on may help with dry coughs. Exposure to smoke prolongs the illness.tcirpThroat Culture ProtcolQ THROAT CULTURE ONLY PROTOCOL Patient's age: {@INPUT(age) patient's age} The patient has a primary doctor at {@INPUT(primaryMD) primary doctor at Mayo Family Clinic NW. Kasson Mayo Family Practice Clinic. Baldwin Family Medicine. Baldwin Community Pediatrics and Adolescent Medicine. Baldwin Community Internal Medicine. } The patient meets the protocol criteria of: {@INPUT(criteria) meets the protocol criteria of: Age > 3 years Temp <104 in a child or <103 in an adult Symptoms < 1 week duration Sore throat present. } {@INPUT(document vital signs) Vital signs are documented on the chart: temperature and weight on child & weight, temperature and B/P on adult} The patient does not have {@INPUT(exclusions) patient does not have Stridor Drooling Inability to swallow Wheezing or other signs of respiratory distress Ear pain > 3 positive cultures in the last 6 months Culture or strep screen done in the last week. } The patient has no history of {@INPUT(PMH) no history of Diabetes HIV Chronic steroid use Immunosuppression Coumadin use. } The patient {@INPUT(outcomes) the patient Meets the throat culture protocol Fails the throat culture protocol due to {@INPUT(failures) fails the throat culture protocol due to} Was referred to a physician/nurse practitioner } Medication allergies: {@INPUT(allergies) medication allergies:} Medication choice: {@INPUT(medication) medication choice: Penicillin VK 250 mg BID x 10 d 25-50 lb Penicillin VK 500 mg BID x 10 d > 50 lb Amoxicillin 250 mg TID x 10 d >25 lb Amoxicillin < 25 lb per MD. USE EES IF ALLERGIC TO PENNICILLIN IF PRESCRIBED EES WAS NOT USING: Theophylline, Tegretol, Mevacor, Pravachol or Simvastatin EES <25 lb per MD EES 100 mg QID x 10 d 15-25 lb EES 200 mg TID x 10 d 26-35 lb EES 200 mg QID x 10 d 36-50 lb EES 400 mg TID x 10 d 57-90 lb EES 400mg mg QID x 10 days >90 lb Other {@INPUT(othermeds) other} None } The Patient/Parent choice of how the medicine was prescribed: {@INPUT chose how the prescription was ordered Tablet Liquid Chewable tablet } Test performed: {@INPUT(test) test performed: Rapid strep screen Strep culture None } Prescription sent to the lab: {@INPUT Prescription sent to the lab: Yes No } Pharmacy chosen {@INPUT pharmacy chosen} {@INPUT select one or both or all American Academy of ENT Surgery, Inc. "Sore Throats: Causes and Cures" MIC204049 Patient given Mayo Clinic Pamphlet MC 1492-01 "Information on Sore Throats" Patient given information on home care of sore throat } Nurse's name: {@INPUT(name) nurse's name:} T@tdateenters today's date{@SHORTDATE}: