interface/forms/bronchitis/new.php

   1 <!-- Form created by Nikolai Vitsyn: 2004/01/23  -->
   2 <!--                          Update 2004/01/29  -->
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 formHeader("Form: bronchitis");
   7 ?>
   8 <html><head>
   9 <SCRIPT LANGUAGE="JavaScript">
  10 <!--
  11
  12    function onset_check (form)   {
  13
  14         var d, s = "Today's date is: "; //Declare variables.
  15         d = new Date(); //Create Date object.
  16         s += (d.getMonth() + 1) + "-"; //Get month
  17         s += d.getDate() + "-"; //Get day
  18         s += d.getYear(); //Get year.
  19
  20     onset_str = form.bronchitis_date_of_illness.value;
  21     if (onset_str == "") {
  22     alert("No valid date into Onset of illness field!!! Enter date as YYYY-MM-DD");
  23     alert(d);
  24
  25         return;
  26       }
  27     if (onset_str.length != 10) {
  28      alert("Your date should be 10 characters");
  29         return;
  30       }
  31     alert("OK, Bye!!!");
  32     return;
  33    }
  34 </SCRIPT>
  35
  36 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  37 </head>
  38 <body <?echo $top_bg_line;?>
  39 topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  40 <form method=post action="<?echo $rootdir;?>/forms/bronchitis/save.php?mode=new" name="my_form">
  41 <br></br>
  42 <span class="title" >Bronchitis Form</span>
  43 <br></br>
  44
  45 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  46 <br>
  47 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link" style="color: #483D8B">[Don't Save]</a>
  48 <br></br>
  49 <span class="text" >Onset of Illness: </span><input type="entry" name="bronchitis_date_of_illness" value=""></input>
  50 <br></br>
  51
  52 <span class="text" >HPI:</span><br></br>
  53 <textarea name="bronchitis_hpi" rows="4" cols="67" wrap="virtual name"></textarea>
  54 <br></br>
  55
  56 <table ><th colspan="5">"Other Pertinent Symptoms":</th>
  57 <tr>
  58 <td width="80" align="right">Fever:</td>
  59 <td><input type="checkbox" name="bronchitis_ops_fever"></input></td>
  60 <td width="100" align="right">Cough:</td>
  61 <td><input type="checkbox" name="bronchitis_ops_cough"></input></td>
  62 <td width="60" align="right">Dizziness:</td>
  63 <td><input type="checkbox" name="bronchitis_ops_dizziness"></input></td>
  64 </tr>
  65 <tr>
  66 <td width="80" align="right">Chest Pain:</td>
  67 <td><input type="checkbox" name="bronchitis_ops_chest_pain"></input></td>
  68 <td width="100" align="right">Dyspnea:</td>
  69 <td><input type="checkbox" name="bronchitis_ops_dyspnea"></input></td>
  70 <td width="60" align="right">Sweating:</td>
  71 <td><input type="checkbox" name="bronchitis_ops_sweating"></input></td>
  72 </tr>
  73 <tr>
  74 <td width="80" align="right">Wheezing:</td>
  75 <td><input type="checkbox" name="bronchitis_ops_wheezing"></input></td>
  76 <td width="100" align="right">Malaise:</td>
  77 <td><input type="checkbox" name="bronchitis_ops_malaise"></input></td>
  78 </tr>
  79 <tr>
  80 <td width="80" align="right">Sputum:</td>
  81 <td><input type="checkbox" name="bronchitis_ops_sputum"></input></td>
  82 <td width="100" align="right">Appearance:</td>
  83 <td><input type="text" name="bronchitis_ops_appearance" size="10" value="none"></input></td>
  84 </tr>
  85 </table>
  86
  87 <table>
  88 <tr>
  89 <td width="205" align="right">All Reviewed and Negative:</td>
  90 <td><input type="checkbox" name="bronchitis_ops_all_reviewed"></input></td>
  91 </tr>
  92 </table>
  93 <br></br>
  94
  95
  96 <table >
  97 <tr>
  98 <td width="60">Review of PMH:</td>
  99 <td align="right"></td>
 100 <td><input type="checkbox" name="bronchitis_review_of_pmh"></input></td>
 101 <td align="right">Medications:</td>
 102 <td><input type="checkbox" name="bronchitis_review_of_medications"></input></td>
 103 <td align="right">Allergies:</td>
 104 <td><input type="checkbox" name="bronchitis_review_of_allergies"></input></td>
 105 <td align="right">Social History:</td>
 106 <td><input type="checkbox" name="bronchitis_review_of_sh"></input></td>
 107 <td align="right">Family History:</td>
 108 <td><input type="checkbox" name="bronchitis_review_of_fh"></input></td>
 109 </tr>
 110 </table>
 111 <br></br>
 112
 113 <table>
 114 <tr>
 115 <td width="60">TM'S:</td>
 116 <td align="right">Normal Right:</td>
 117 <td><input type="checkbox" name="bronchitis_tms_normal_right"></input></td>
 118 <td align="right">Left:</td>
 119 <td><input type="checkbox" name="bronchitis_tms_normal_left"></input></td>
 120
 121 <td width="80">NARES: </td>
 122 <td align="right">Normal Right</td>
 123 <td><input type="checkbox" name="bronchitis_nares_normal_right"></input></td>
 124 <td align="right">Left:</td>
 125 <td><input type="checkbox" name="bronchitis_nares_normal_left"></input></td>
 126 </tr>
 127
 128 <tr>
 129 <td width="50"></td>
 130 <td align="right">Thickened Right:</td>
 131 <td><input type="checkbox" name="bronchitis_tms_thickened_right"></input></td>
 132 <td align="right">Left:</td>
 133 <td><input type="checkbox" name="bronchitis_tms_thickened_left"></input></td>
 134
 135 <td width="80"></td>
 136 <td align="right">Swelling Right</td>
 137 <td><input type="checkbox" name="bronchitis_nares_swelling_right"></input></td>
 138 <td align="right">Left:</td>
 139 <td><input type="checkbox" name="bronchitis_nares_swelling_left"></input></td>
 140 </tr>
 141
 142 <tr>
 143 <td width="50"></td>
 144 <td align="right">A/F Level Right:</td>
 145 <td><input type="checkbox" name="bronchitis_tms_af_level_right"></input></td>
 146 <td align="right">Left:</td>
 147 <td><input type="checkbox" name="bronchitis_tms_af_level_left"></input></td>
 148
 149 <td width="80"></td>
 150 <td align="right">Discharge Right:</td>
 151 <td><input type="checkbox" name="bronchitis_nares_discharge_right"></input></td>
 152 <td align="right">Left:</td>
 153 <td><input type="checkbox" name="bronchitis_nares_discharge_left"></input></td>
 154 </tr>
 155
 156 <tr>
 157 <td width="50"></td>
 158 <td align="right">Retracted Right:</td>
 159 <td><input type="checkbox" name="bronchitis_tms_retracted_right"></input></td>
 160 <td align="right">Left:</td>
 161 <td><input type="checkbox" name="bronchitis_tms_retracted_left"></input></td>
 162 </tr>
 163
 164 <tr>
 165 <td width="50"></td>
 166 <td align="right">Bulging Right:</td>
 167 <td><input type="checkbox" name="bronchitis_tms_bulging_right"></input></td>
 168 <td align="right">Left:</td>
 169 <td><input type="checkbox" name="bronchitis_tms_bulging_left"></input></td>
 170
 171 </tr>
 172
 173 <tr>
 174 <td width="50"></td>
 175 <td align="right">Perforated Right:</td>
 176 <td><input type="checkbox" name="bronchitis_tms_perforated_right"></input></td>
 177 <td align="right">Left:</td>
 178 <td><input type="checkbox" name="bronchitis_tms_perforated_left"></input></td>
 179 </tr>
 180 </table>
 181
 182 <table>
 183 <tr>
 184 <td width="220" align="right">Not Examined:</td>
 185 <td><input type="checkbox" name="bronchitis_tms_nares_not_examined"></input></td>
 186 </tr>
 187 </table>
 188 <br></br>
 189
 190 <table>
 191 <tr>
 192 <td width="90">SINUS TENDERNESS:</td>
 193 <td align="right">No Sinus Tenderness:</td>
 194 <td><input type="checkbox" name="bronchitis_no_sinus_tenderness"></input></td>
 195 <td align="right"></td>
 196
 197 <td width="90">OROPHARYNX: </td>
 198 <td align="right">Normal Oropharynx:</td>
 199 <td><input type="checkbox" name="bronchitis_oropharynx_normal"></input></td>
 200 <td align="right"></td>
 201 </tr>
 202
 203 <tr>
 204 <td width="50"></td>
 205 <td align="right">Frontal Right:</td>
 206 <td><input type="checkbox" name="bronchitis_sinus_tenderness_frontal_right"></input></td>
 207 <td align="right">Left:</td>
 208 <td><input type="checkbox" name="bronchitis_sinus_tenderness_frontal_left"></input></td>
 209 <td align="right">Erythema:</td>
 210 <td><input type="checkbox" name="bronchitis_oropharynx_erythema"></input></td>
 211 <td align="right">Exudate:</td>
 212 <td><input type="checkbox" name="bronchitis_oropharynx_exudate"></input></td>
 213 <td align="right">Abcess:</td>
 214 <td><input type="checkbox" name="bronchitis_oropharynx_abcess"></input></td>
 215 <td align="right">Ulcers:</td>
 216 <td><input type="checkbox" name="bronchitis_oropharynx_ulcers"></input></td>
 217 </tr>
 218
 219 <tr>
 220 <td width="50"></td>
 221 <td align="right">Maxillary Right:</td>
 222 <td><input type="checkbox" name="bronchitis_sinus_tenderness_maxillary_right"></input></td>
 223 <td align="right">Left:</td>
 224 <td><input type="checkbox" name="bronchitis_sinus_tenderness_maxillary_left"></input></td>
 225
 226 <td width="120" align="right">Appearance:</td>
 227 <td><input type="text" name="bronchitis_oropharynx_appearance" size="10" value="normal"></input></td>
 228 </tr>
 229 </table>
 230
 231 <table>
 232 <tr>
 233 <td width="238" align="right" >Not Examined: </td>
 234 <td><input type="checkbox" name="bronchitis_sinus_tenderness_not_examined"></input></td>
 235 <td width="268" align="right" >Not Examined: </td>
 236 <td><input type="checkbox" name="bronchitis_oropharynx_not_examined"></input></td>
 237 </tr>
 238 </table>
 239 <br></br>
 240
 241 <table >
 242 <tr>
 243 <td width="60">HEART:</td>
 244 <td align="right">laterally displaced PMI:</td>
 245 <td><input type="checkbox" name="bronchitis_heart_pmi"></input></td>
 246 <td align="right">S3:</td>
 247 <td><input type="checkbox" name="bronchitis_heart_s3"></input></td>
 248 <td align="right">S4:</td>
 249 <td><input type="checkbox" name="bronchitis_heart_s4"></input></td>
 250 </tr>
 251 <tr>
 252 <td width="60"></td>
 253 <td align="right">Click:</td>
 254 <td><input type="checkbox" name="bronchitis_heart_click"></input></td>
 255 <td align="right">Rub:</td>
 256 <td><input type="checkbox" name="bronchitis_heart_rub"></input></td>
 257 </tr>
 258 </table>
 259
 260 <table>
 261 <tr>
 262 <td width="60"></td>
 263 <td>Murmur:</td>
 264 <td><input type="text" name="bronchitis_heart_murmur" size="10" value="none"></input></td>
 265 <td>Grade:</td>
 266 <td><input type="text" name="bronchitis_heart_grade" size="10" value="n/a"></input></td>
 267 <td>Location:</td>
 268 <td><input type="text" name="bronchitis_heart_location" size="10" value="n/a"></input></td>
 269 </tr>
 270 </table>
 271
 272 <table>
 273 <tr>
 274 <td width="203" align="right" >Normal Cardiac Exam: </td>
 275 <td><input type="checkbox" name="bronchitis_heart_normal"></input></td>
 276 <td width="93" align="right">Not Examined: </td>
 277 <td><input type="checkbox" name="bronchitis_heart_not_examined"></input></td>
 278 </tr>
 279 </table>
 280 <br></br>
 281
 282 <table>
 283 <tr>
 284 <td width="60">LUNGS:</td>
 285 <td width="106">Breath Sounds:</td>
 286 <td align="right"> normal:</td>
 287 <td><input type="checkbox" name="bronchitis_lungs_bs_normal"></input></td>
 288 <td align="right">reduced:</td>
 289 <td><input type="checkbox" name="bronchitis_lungs_bs_reduced"></input></td>
 290 <td align="right">increased:</td>
 291 <td><input type="checkbox" name="bronchitis_lungs_bs_increased"></input></td>
 292 </tr>
 293
 294 <tr>
 295 <td width="60"></td>
 296 <td>Crackles:</td>
 297 <td align="right">LLL:</td>
 298 <td><input type="checkbox" name="bronchitis_lungs_crackles_lll"></input></td>
 299 <td align="right">RLL:</td>
 300 <td><input type="checkbox" name="bronchitis_lungs_crackles_rll"></input></td>
 301 <td align="right">Bilateral:</td>
 302 <td><input type="checkbox" name="bronchitis_lungs_crackles_bll"></input></td>
 303 </tr>
 304
 305 <tr>
 306 <td width="60"></td>
 307 <td>Rubs:</td>
 308 <td align="right">LLL:</td>
 309 <td><input type="checkbox" name="bronchitis_lungs_rubs_lll"></input></td>
 310 <td align="right">RLL:</td>
 311 <td><input type="checkbox" name="bronchitis_lungs_rubs_rll"></input></td>
 312 <td align="right">Bilateral:</td>
 313 <td><input type="checkbox" name="bronchitis_lungs_rubs_bll"></input></td>
 314 </tr>
 315
 316 <tr>
 317 <td width="60"></td>
 318 <td>Wheezes:</td>
 319 <td align="right">LLL:</td>
 320 <td><input type="checkbox" name="bronchitis_lungs_wheezes_lll"></input></td>
 321 <td align="right">RLL:</td>
 322 <td><input type="checkbox" name="bronchitis_lungs_wheezes_rll"></input></td>
 323 <td align="right">Bilateral:</td>
 324 <td><input type="checkbox" name="bronchitis_lungs_wheezes_bll"></input></td>
 325 <td align="right">Diffuse:</td>
 326 <td><input type="checkbox" name="bronchitis_lungs_wheezes_dll"></input></td>
 327 </tr>
 328 </table>
 329
 330 <table>
 331 <tr>
 332 <td width="218" align="right" >Normal Lung Exam: </td>
 333 <td><input type="checkbox" name="bronchitis_lungs_normal_exam"></input></td>
 334 <td width="140" align="right" >Not Examined: </td>
 335 <td><input type="checkbox" name="bronchitis_lungs_not_examined"></input></td>
 336 </tr>
 337 </table>
 338 <br></br>
 339
 340 <span class="text" >Diagnostic Tests:</span><br></br>
 341 <textarea name="bronchitis_diagnostic_tests" rows="4" cols="67" wrap="virtual name"></textarea>
 342 <br></br>
 343
 344 <span class="text" >Diagnosis: </span>
 345 <table><tr>
 346    <td>
 347    <select name="diagnosis1_bronchitis_form" >
 348       <option value="None">None</option>
 349       <option value="465.9, URI">465.9, URI</option>
 350       <option value="466.0, Bronchitis, Acute NOS">466.0, Bronchitis, Acute NOS</option>
 351       <option value="493.92, Astma, Acute Exac.">493.92, Asthma, Acute Exac.</option>
 352       <option value="491.8, Bronchitis, Chronic">491.8, Bronchitis, Chronic</option>
 353       <option value="496.0, COPD">496.0, COPD</option>
 354       <option value="491.21,COPD Exacerbation">491.21, COPD Exacerbation</option>
 355       <option value="486.0, Pneumonia, Acute">486.0, Pneumonia, Acute</option>
 356       <option value="519.7, Bronchospasm">519.7, Bronchospasm</option>
 357       <br><br>
 358    </select>
 359    </td>
 360 </tr>
 361 <tr>
 362    <td>
 363    <select name="diagnosis2_bronchitis_form">
 364       <option value="None">None</option>
 365       <option value="465.9, URI">465.9, URI</option>
 366       <option value="466.0, Bronchitis, Acute NOS">466.0, Bronchitis, Acute NOS</option>
 367       <option value="493.92, Asthma, Acute Exac.">493.92, Asthma, Acute Exac.</option>
 368       <option value="491.8, Bronchitis, Chronic">491.8, Bronchitis, Chronic</option>
 369       <option value="496.0, COPD">496.0, COPD</option>
 370       <option value="491.21,COPD Exacerbation">491.21, COPD Exacerbation</option>
 371       <option value="486.0, Pneumonia, Acute">486.0, Pneumonia, Acute</option>
 372       <option value="519.7, Bronchospasm">519.7, Bronchospasm</option>
 373       <br><br>
 374    </select>
 375    </td>
 376 </tr>
 377 <tr>
 378    <td>
 379    <select name="diagnosis3_bronchitis_form">
 380       <option value="None">None</option>
 381       <option value="465.9, URI">465.9, URI</option>
 382       <option value="466.0, Bronchitis, Acute NOS">466.0, Bronchitis, Acute NOS</option>
 383       <option value="493.92, Asthma, Acute Exac.">493.92, Asthma, Acute Exac.</option>
 384       <option value="491.8, Bronchitis, Chronic">491.8, Bronchitis, Chronic</option>
 385       <option value="496.0, COPD">496.0, COPD</option>
 386       <option value="491.21,COPD Exacerbation">491.21, COPD Exacerbation</option>
 387       <option value="486.0, Pneumonia, Acute">486.0, Pneumonia, Acute</option>
 388       <option value="519.7, Bronchospasm">519.7, Bronchospasm</option>
 389      <br><br>
 390    </select>
 391    </td>
 392 </tr>
 393 <tr>
 394    <td>
 395    <select name="diagnosis4_bronchitis_form">
 396       <option value="None">None</option>
 397       <option value="465.9, URI">465.9, URI</option>
 398       <option value="466.0, Bronchitis, Acute NOS">466.0, Bronchitis, Acute NOS</option>
 399       <option value="493.92, Asthma, Acute Exac.">493.92, Asthma, Acute Exac.</option>
 400       <option value="491.8, Bronchitis, Chronic">491.8, Bronchitis, Chronic</option>
 401       <option value="496.0, COPD">496.0, COPD</option>
 402       <option value="491.21,COPD Exacerbation">491.21, COPD Exacerbation</option>
 403       <option value="486.0, Pneumonia, Acute">486.0, Pneumonia, Acute</option>
 404       <option value="519.7, Bronchospasm">519.7, Bronchospasm</option>
 405      <br><br>
 406    </select>
 407    </td>
 408 </tr>
 409 <table>
 410 <br></br>
 411
 412 <span class="text" >Additional Diagnosis: </span><br></br>
 413 <textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name"></textarea>
 414 <br></br>
 415
 416 <span class="text" >Treatment: </span><br></br>
 417 <textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name"></textarea>
 418
 419 <br></br>
 420 <input type="Button" value="Check Input Data" style="color: #483D8B" onClick = "onset_check(my_form)"<br>
 421 <br>
 422 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
 423 <br>
 424 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link" style="color: #483D8B">[Don't Save]</a>
 425 </form>
 426
 427 <?php
 428 formFooter();
 429 ?>