The Eloquent Physician - a Medical Record Software Program. Sample Doctor’s Chart Note

HISTORY: (fullName) is a {1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100} year-old {Oriental | | Caucasian | Black | Hispanic | Asian | Indian | American Indian} (sex) who presents with pain in the right knee. The patient states that the pain began (dateOfInjury) at {}. (He_She) {hit | fell | fell against | bumped | twisted | torqued | tripped | flew | touched} { | the affected knee in the auto accident}. (He_She) was involved in a motor vehicle accident on (dateOfInjury). (He_She) was seated in the {driver's seat | front right passenger's seat | back seat}. He {was | was not} wearing a seatbelt. An airbag {deployed | did not deploy}. (He_She) felt {{SYMPTOM} in the {KNEE ANATOMY SURFACE} | | a fracture of the {KNEE ANATOMY BONE} | a mass over the {KNEE ANATOMY SURFACE} | popping under the patella of the {right | left} knee | locking of the {right | left} knee in a flexed position | locking of the {right | left} knee in an extended position | a feeling that the {right | left} knee wants to give out | pain in the medial joint line of the {right | left} knee | pain in the lateral joint line of the {right | left} knee | pain in the popliteal fossa of the {right | left} knee | pain in the {right | left} knee with squatting | pain with forced extension of the {right | left} knee | pain with prolonged ambulation and standing on the {right | left} knee} and heard {a pop | a click | a snap | | no audible sound} from the knee. There was {no | some | mild | moderate | significant} swelling {immediately thereafter | shortly thereafter | that evening | the following morning | later that week | later that month}. (He_She) was {able | unable | barely able} to bear weight. (He_She) was initially evaluated at {EVALUATION }. { | Prior treatment was anti-inflammatory medications. | Prior treatment has consisted of physical therapy. | Prior treatment has consisted of splinting. | Prior treatment has consisted of injections. | Prior treatment has consisted of operative treatment. | | There has been no prior treatment for this condition. | Prior treatment has included anti-inflammatory medications. | Prior treatment has included physical therapy. | Prior treatment has included splinting. | Prior treatment has included injections. | Prior treatment has included operative treatment.}. (He_She) comes in today for further care. The patient currently complains of {{SYMPTOM} in the {KNEE ANATOMY SURFACE} | | a fracture of the {KNEE ANATOMY BONE} | a mass over the {KNEE ANATOMY SURFACE} | popping under the patella of the {right | left} knee | locking of the {right | left} knee in a flexed position | locking of the {right | left} knee in an extended position | a feeling that the {right | left} knee wants to give out | pain in the medial joint line of the {right | left} knee | pain in the lateral joint line of the {right | left} knee | pain in the popliteal fossa of the {right | left} knee | pain in the {right | left} knee with squatting | pain with forced extension of the {right | left} knee | pain with prolonged ambulation and standing on the {right | left} knee}. (He_She) has a {negative | positive} "two fist" sign. The knee pain {does | does not} wake (him_her) at night. (He_She) {does | does not} sleep with a pillow between (his_her) legs. Climbing up stairs causes {no | some | mild | moderate | significant} pain. Going down stairs causes {no | some | mild | moderate | significant} pain. { | The patient notes that there was a new injury to the knee after the initial injury. | The patient notes that there were no new injuries to the knee after the initial injury.} (He_She) is currently taking { | Aspirin | Celebrex | narcotic pain killers | no medication | NSAID's | Tylenol | Vioxx} for (his_her) knee injury. REVIEW OF SYSTEMS: { | | Eyes: Negative | Eyes: Blurry Vision | Eyes: Double Vision | Eyes: Loss of Visual Acuity}{ | | Ear, Nose, Mouth, Throat: Negative | Ear, Nose, Mouth, Throat: Loss of Auditory Acuity | Ear, Nose, Mouth, Throat: Ear Pain | Ear, Nose, Mouth, Throat: Hoarseness | Ear, Nose, Mouth, Throat: Sore Throat | Ear, Nose, Mouth, Throat: Tinnitus}{ | Cardiovascular: Shortness of Breath Cardiovascular: Carotid stenosis | Cardiovascular: Femoral stenosis | Cardiovascular: Deep Venous Thrombosis | Cardiovascular: Vena Cava filter | Cardiovascular: TIA | Cardiovascular: CVA | | | Cardiovascular: Negative | Cardiovascular: Arm Pain | Cardiovascular: Chest Pain | Cardiovascular: Shortness of Breath}{ | | | Respiratory: Negative | Respiratory: Coughing | Respiratory: Difficulty Breathing | Respiratory: Nasal Congestion | Respiratory: Shortness of Breath}{ | | Gastrointestinal: Negative | Gastrointestinal: Abdominal Pain | Gastrointestinal: Abdominal Swelling | Gastrointestinal: Change in Bowel Habits | Gastrointestinal: Constipation | Gastrointestinal: Diarrhea | Gastrointestinal: Excessive Gas Production | Gastrointestinal: Loss of Appetite | Gastrointestinal: Loss of Weight | Gastrointestinal: Vomiting}{ | Musculoskeletal: Swollen Joints | | Musculoskeletal: Negative | Musculoskeletal: Back Pain | Musculoskeletal: Neck Pain | Musculoskeletal: Morning Stiffness | Musculoskeletal: Painful Joints}{ | | Neurological: Negative | Neurological: Confusion | Neurological: Dizziness | Neurological: Fainting | Neurological: Headaches | Neurological: Memory Loss Neurological: Seizures | Neurological: Speech Difficulties | Neurological: Twitching}{ | | Endocrine: Negative | Endocrine: Excessive Sweating | Endocrine: Excessive Thirst | Endocrine: Generalized Fatigue | Endocrine: Nervousness} SOCIAL HISTORY: Occupation: (He_She) is { | a carpenter | a computer operator | a construction worker | a cook | a dishwasher | a firefighter | a flight attendant | a medical doctor | a pilot | a plumber | a police officer | a professional athlete | a secretary | a security guard | a typist | an electrician}. Tobacco Use: {No tobacco use. | 1 pack per day smoker. | 2 pack per day smoker. | 3 pack per day smoker. | Cigar smoker. | Chews tobacco.} ETOH Use: {one beer per day | two beers per day | three beers per day | four beers per day | five beers per day | twelve pack per day | a case of beer each day | one ounce of hard liquor each day | two ounces of hard liquor each day | three ounces of hard liquor each day | four ounces of hard liquor each day | half of a fifth of hard liquor each day | a fifth of hard liquor each day}. MEDICATIONS: {Vicodin | Oxycontin | Percodan | Percocet | Lortab | Lorcet | Vicodin ES | Darvocet N100 | Skelaxin | Zanaflex | Celebrex | Vioxx | Voltaren | Anti-biotics | Anti-Hypertensive medication | Cholesterol Medication | Pepsid | Neurontin | Elavil | None | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Arthrotec | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} ALLERGIES: { MEDICATION ALLERGIES: NKDA | MEDICATION ALLERGIES: Aspirin results in {ALLERGIC REACTION} | MEDICATION ALLERGIES: Penicillin results in {ALLERGIC REACTION} | MEDICATION ALLERGIES: Sulfa Drugs result in {ALLERGIC REACTION} | MEDICATION ALLERGIES: {Vicodin | Oxycontin | Percodan | Percocet | Lortab | Lorcet | Vicodin ES | Darvocet N100 | Skelaxin | Zanaflex | Celebrex | Vioxx | Voltaren | Anti-biotics | Anti-Hypertensive medication | Cholesterol Medication | Pepsid | Neurontin | Elavil | None | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Arthrotec | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} results in {ALLERGIC REACTION}} PHYSICAL EXAMINATION: Ł |SPECIFIC TESTS |RIGHT|LEFT| |Effusion |{no | some | mild | moderate | significant}|{no | some | mild | moderate | significant}| |Soft Tissue Swelling |{no | mild | moderate | severe}|{no | mild | moderate | severe}| |Scars |{Inspection of the right knee reveals well healed portal scars from a previous arthroscopy. | Inspection of the left knee reveals well healed portal scars from a previous arthroscopy. | Inspection of the left knee reveals a well healed mid-line scar from previous ACL reconstruction. | Inspection of the right knee reveals a well healed mid-line scar from previous ACL reconstruction. | Inspection of the right knee reveals no surgical scars. | Inspection of the left knee reveals no surgical scars. | Inspection of bilateral knees reveals no surgical scars.}|{Inspection of the right knee reveals well healed portal scars from a previous arthroscopy. | Inspection of the left knee reveals well healed portal scars from a previous arthroscopy. | Inspection of the left knee reveals a well healed mid-line scar from previous ACL reconstruction. | Inspection of the right knee reveals a well healed mid-line scar from previous ACL reconstruction. | Inspection of the right knee reveals no surgical scars. | Inspection of the left knee reveals no surgical scars. | Inspection of bilateral knees reveals no surgical scars.}| |Ecchymosis |{normal | decreased | diffuse | none | patchy}|{normal | decreased | diffuse | none | patchy}| |Induration |{normal | none | mild | moderate | severe | diffuse | decreased | patchy}|{normal | none | mild | moderate | severe | diffuse | decreased | patchy}| |Erythema |{decreased | normal | increased | mild | moderate | severe | none | patchy | diffuse | | 4 mm | 5 mm | 6 mm | 7 mm | 8 mm | 9 mm | 10 mm | over 10 mm}|{decreased | normal | increased | mild | moderate | severe | none | patchy | diffuse | | 4 mm | 5 mm | 6 mm | 7 mm | 8 mm | 9 mm | 10 mm | over 10 mm}| |Neurovascular Exam |{decreased | normal | increased}|{decreased | normal | increased}| |ROM |{The patients right knee range of motion is observed as follows: Knee flexion - {KNEE FLEXION} degrees Active knee extension - {KNEE ACTIVE EXTENSION} degrees | The patients left knee range of motion is observed as follows: Knee flexion - {KNEE FLEXION} degrees Active knee extension - {KNEE ACTIVE EXTENSION} degrees | The patient has deep flexion pain in the left knee with limited range of motion. | The patient has deep flexion pain in the right knee with limited range of motion. | The patient lacks terminal extension of the left knee. | The patient lacks terminal extension of the right knee. | The patient has full range of motion in the right knee. | The patient has full range of motion in the left knee. | The patient has full range of motion in bilateral knees.}|{The patients right knee range of motion is observed as follows: Knee flexion - {KNEE FLEXION} degrees Active knee extension - {KNEE ACTIVE EXTENSION} degrees | The patients left knee range of motion is observed as follows: Knee flexion - {KNEE FLEXION} degrees Active knee extension - {KNEE ACTIVE EXTENSION} degrees | The patient has deep flexion pain in the left knee with limited range of motion. | The patient has deep flexion pain in the right knee with limited range of motion. | The patient lacks terminal extension of the left knee. | The patient lacks terminal extension of the right knee. | The patient has full range of motion in the right knee. | The patient has full range of motion in the left knee. | The patient has full range of motion in bilateral knees.}| |Patello-Femoral Crepitus|{positive | equivocal | negative}|{positive | equivocal | negative}| |Popping |{positive | equivocal | negative}|{positive | equivocal | negative}| |Patella Inhibition Test |{positive | equivocal | negative}|{positive | equivocal | negative}| |Patella Apprehension |{no | some | mild | moderate | significant}|{no | some | mild | moderate | significant}| |Patellar Tracking |{no | mild | moderate | severe}|{no | mild | moderate | severe}| |Q Angle |{5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100 | 105 | 110 | 115 | 120 | 125 | 130 | 135 | 140 | 145 | 150 | 155 | 160 | 165 | 170 | 175 | 180}|{5 | 10 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100 | 105 | 110 | 115 | 120 | 125 | 130 | 135 | 140 | 145 | 150 | 155 | 160 | 165 | 170 | 175 | 180}| |Lachman's Test |{}|{}| |Pivot Shift Test |{positive | equivocal | negative}|{positive | equivocal | negative}| |Varus Stress Test 0 deg |{no | some | mild | moderate | significant}|{no | some | mild | moderate | significant}| |Varus Stress Test 30 deg|{no | mild | moderate | severe}|{no | mild | moderate | severe}| |Valgus Stress Test at 0 |{no | some | mild | moderate | significant}|{no | some | mild | moderate | significant}| |Valgus Stress Test at 30|{no | some | mild | moderate | significant}|{no | some | mild | moderate | significant}| |Anterior Drawer |{positive | equivocal | negative}|{positive | equivocal | negative}| |Posterior Drawer |{positive | equivocal | negative}|{positive | equivocal | negative}| |McMurray's Test Medial |{positive | equivocal | negative}|{positive | equivocal | negative}| |McMurray's Test Lateral |{positive | equivocal | negative}|{positive | equivocal | negative}| |Extension Bounce Test |{positive | equivocal | negative}|{positive | equivocal | negative}| |Figure 4 Test |{positive | equivocal | negative}|{positive | equivocal | negative}| |Quadriceps Atrophy |{no | some | mild | moderate | significant}|{no | some | mild | moderate | significant}| |Quadriceps Tone |{well defined | normal | poorly defined}|{well defined | normal | poorly defined}| |Comments |{ | Further examination of the knee is otherwise unremarkable.}|{ | Further examination of the knee is otherwise unremarkable.}| IMAGING STUDIES X-rays of the right knee, AP and lateral views, were reviewed with the patient. They revealed the joint spaces to be well maintained, as are the medial and lateral tibiofemoral joint compartments. There is no evidence of osteophyte formation. There is no evidence of fracture, dislocation, or osseous pathology affecting the lower end of the femur or upper end of the tibia. X-ray films of the bilateral knees obtained in the office today are within normal limits. There is evidence of old Osgood- Schlatter's disease. There are no significant degenerative changes present. The joint spaces are well maintained with no calcification within the menisci. The patellae are appropriately positioned. No fractures or dislocations are noted. IMPRESSION Torn Right Medial Meniscus Tear. Based upon the history and symptoms as presented by the patient and the documentation provided, it is most probable within a reasonable degree of medical probability, that the findings are the result of the motor vehicle accident of (dateOfInjury). PLAN A lengthy discussion was held with the patient regardings diagnosis and treatment options. At this point I would like him to begin a course of Physical therapy as well as a home exercise program. He will take {Vicodin | Oxycontin | Percodan | Percocet | Lortab | Lorcet | Vicodin ES | Darvocet N100 | Skelaxin | Zanaflex | Celebrex | Vioxx | Voltaren | Anti-biotics | Anti-Hypertensive medication | Cholesterol Medication | Pepsid | Neurontin | Elavil | None | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Arthrotec | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} with appropriate precautions. At this time I believe the patient would benefit from a therapeutic and diagnostic injection. Therefore the {right | left} knee is prepped with a {Betadyne | alcohol} solution and using sterile gloves and technique, a solution consisting of {2cc of lidocaine 1% with 2cc of Marcaine 0.5% and 1cc of Celestone | 1cc of Sarapin}, {1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 20 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 100} cc, is injected into the knee. The patient tolerated the procedure well and there were no complications. (He_She) is told to ice the area if there is any discomfort over the next several days. (He_She) is also asked to contact the office if (he_she) notices any untoward reaction from the injection. An MRI scan will be ordered if the patient does not improve over time. (firstName) has been asked to return to the office in {1 day | 2 days | 3 days | 5 days | 1 week | 2 weeks | 3 weeks | 4 weeks | 6 weeks | 2 months | 3 months | 6 months | one year} to evaluate (his_her) response to the aforementioned modalities. If (his_her) response has not been satisfactory then surgical options will be discussed on the next evaluation.