interface/forms/bronchitis/view.php

   1 <?php
   2
   3 /**
   4  * ankleinjury view.php
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    Nikolai Vitsyn
   9  * @author    cfapress <cfapress>
  10  * @author    Robert Down <robertdown@live.com>
  11  * @author    Brady Miller <brady.g.miller@gmail.com>
  12  * @copyright Copyright (c) 2004 Nikolai Vitsyn
  13  * @copyright Copyright (c) 2008 cfapress <cfapress>
  14  * @copyright Copyright (c) 2017-2022 Robert Down <robertdown@live.com>
  15  * @copyright Copyright (c) 2017-2019 Brady Miller <brady.g.miller@gmail.com>
  16  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  17  */
  18
  19 require_once(__DIR__ . "/../../globals.php");
  20
  21 use OpenEMR\Common\Csrf\CsrfUtils;
  22 use OpenEMR\Core\Header;
  23
  24 $returnurl = 'encounter_top.php';
  25 ?>
  26 <html><head>
  27     <?php Header::setupHeader(); ?>
  28 </head>
  29 <body class="body_top">
  30 <?php
  31 require_once("$srcdir/api.inc.php");
  32 $obj = formFetch("form_bronchitis", $_GET["id"]);
  33 ?>
  34 <form method=post action="<?php echo $rootdir?>/forms/bronchitis/save.php?mode=update&id=<?php echo attr_url($_GET["id"]); ?>" name="my_form">
  35 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
  36
  37 <span class="title"><?php echo xlt('Bronchitis Form'); ?></span><br /><br />
  38
  39 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php echo xlt('Save'); ?>]</a>
  40 <br />
  41 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  42  onclick="top.restoreSession()">[<?php echo xlt('Don\'t Save Changes'); ?>]</a>
  43 <br /><br />
  44
  45 <span class=text><?php echo xlt('Onset of Ilness: '); ?></span><input type="text" name="bronchitis_date_of_illness" value="<?php echo attr($obj["bronchitis_date_of_illness"]);?>" ><br /><br />
  46
  47 <span class=text><?php echo xlt('HPI:'); ?> </span><br /><textarea cols=67 rows=8 wrap=virtual name="bronchitis_hpi" ><?php echo text($obj["bronchitis_hpi"]);?></textarea><br /><br />
  48
  49
  50 <table><th colspan="5">"<?php echo xlt('Other Pertinent Symptoms'); ?> ":</th>
  51 <tr>
  52 <td width="60" align="right"><?php echo xlt('Fever:'); ?> </td>
  53 <td><input type=checkbox name="bronchitis_ops_fever" <?php if ($obj["bronchitis_ops_fever"] == "on") {
  54     echo "checked";
  55                                                      };?>><span class=text></span><br />
  56
  57 <td width="140" align="right"><?php echo xlt('Cough:'); ?> </td>
  58 <td><input type=checkbox name="bronchitis_ops_cough" <?php if ($obj["bronchitis_ops_cough"] == "on") {
  59     echo "checked";
  60                                                      };?>><span class=text></span><br />
  61
  62 <td width="170" align="right"><?php echo xlt('Dizziness:'); ?> </td>
  63 <td><input type=checkbox name="bronchitis_ops_dizziness" <?php if ($obj["bronchitis_ops_dizziness"] == "on") {
  64     echo "checked";
  65                                                          };?>><span class=text></span><br />
  66 </tr>
  67
  68 <tr>
  69 <td width="60" align="right"><?php echo xlt('Chest Pain:'); ?> </td>
  70 <td><input type=checkbox name="bronchitis_ops_chest_pain" <?php if ($obj["bronchitis_ops_chest_pain"] == "on") {
  71     echo "checked";
  72                                                           };?>><span class=text></span><br />
  73 <td width="130" align="right"><?php echo xlt('Dyspnea:'); ?> </td>
  74 <td><input type=checkbox name="bronchitis_ops_dyspnea" <?php if ($obj["bronchitis_ops_dyspnea"] == "on") {
  75     echo "checked";
  76                                                        };?>><span class=text></span><br />
  77 <td width="180" align="right"><?php echo xlt('Sweating:'); ?> </td>
  78 <td><input type=checkbox name="bronchitis_ops_sweating" <?php if ($obj["bronchitis_ops_sweating"] == "on") {
  79     echo "checked";
  80                                                         };?>><span class=text></span><br />
  81 </tr>
  82
  83 <tr>
  84 <td width="60" align="right"><?php echo xlt('Wheezing:'); ?> </td>
  85 <td><input type=checkbox name="bronchitis_ops_wheezing" <?php if ($obj["bronchitis_ops_wheezing"] == "on") {
  86     echo "checked";
  87                                                         };?>><span class=text></span><br />
  88
  89 <td width="130" align="right"><?php echo xlt('Malaise:'); ?> </td>
  90 <td><input type=checkbox name="bronchitis_ops_malaise" <?php if ($obj["bronchitis_ops_malaise"] == "on") {
  91     echo "checked";
  92                                                        };?>><span class=text></span><br />
  93 </tr>
  94
  95 <tr>
  96 <td width="60" align="right"><?php echo xlt('Sputum:'); ?> </td>
  97 <td><input type=checkbox name="bronchitis_ops_sputum" <?php if ($obj["bronchitis_ops_sputum"] == "on") {
  98     echo "checked";
  99                                                       };?>><span class=text></span><br /></td>
 100
 101 <td width="130" align="right"><?php echo xlt('Appearance:'); ?>  <span class="text"></span></td>
 102 <td><input type="text" name="bronchitis_ops_appearance" value="<?php echo
 103 stripslashes($obj["bronchitis_ops_appearance"]);?>" size="15"></td>
 104 </tr>
 105 </table>
 106
 107 <table><tr>
 108 <td width="227" align="right"><?php echo xlt('All Reviewed and Negative:'); ?> </td>
 109 <td><input type=checkbox name="bronchitis_ops_all_reviewed" <?php if ($obj["bronchitis_ops_all_reviewed"] == "on") {
 110     echo "checked";
 111                                                             };?>><span class=text></span><br />
 112 </tr>
 113 </table>
 114 <br /><br />
 115
 116 <table >
 117 <tr>
 118 <td width="60" align="right"><?php echo xlt('Review of PMH:'); ?> </td>
 119 <td><input type=checkbox name="bronchitis_review_of_pmh" <?php if ($obj["bronchitis_review_of_pmh"] == "on") {
 120     echo "checked";
 121                                                          };?>><span class=text></span><br /></td>
 122 <td align="right"><?php echo xlt('Medications:'); ?> </td>
 123 <td><input type=checkbox name="bronchitis_review_of_medications" <?php if ($obj["bronchitis_review_of_medications"] == "on") {
 124     echo "checked";
 125                                                                  };?>><span class=text></span><br /></td>
 126 <td align="right"><?php echo xlt('Allergies:'); ?> </td>
 127 <td><input type=checkbox name="bronchitis_review_of_allergies" <?php if ($obj["bronchitis_review_of_allergies"] == "on") {
 128     echo "checked";
 129                                                                };?>><span class=text></span><br /></td>
 130 <td align="right"><?php echo xlt('Social History:'); ?> </td>
 131 <td><input type=checkbox name="bronchitis_review_of_sh" <?php if ($obj["bronchitis_review_of_sh"] == "on") {
 132     echo "checked";
 133                                                         };?>><span class=text></span><br /></td>
 134 <td align="right"><?php echo xlt('Family History:'); ?> </td>
 135 <td><input type=checkbox name="bronchitis_review_of_fh" <?php if ($obj["bronchitis_review_of_fh"] == "on") {
 136     echo "checked";
 137                                                         };?>><span class=text></span><br /></td>
 138 </tr>
 139 </table>
 140 <br /><br />
 141
 142
 143 <table>
 144 <tr>
 145 <td width="60"><?php echo xlt('TM\'S:'); ?> </td>
 146 <td align="right"><?php echo xlt('Normal Right:'); ?> </td>
 147 <td><input type=checkbox name="bronchitis_tms_normal_right" <?php if ($obj["bronchitis_tms_normal_right"] == "on") {
 148     echo "checked";
 149                                                             };?>><span class=text></span><br />
 150 <td align="right"><?php echo xlt('Left:'); ?> </td>
 151 <td><input type=checkbox name="bronchitis_tms_normal_left" <?php if ($obj["bronchitis_tms_normal_left"] == "on") {
 152     echo "checked";
 153                                                            };?>><span class=text></span><br />
 154 <td align="right"><?php echo xlt('NARES: Normal Right'); ?> </td>
 155 <td><input type=checkbox name="bronchitis_nares_normal_right" <?php if ($obj["bronchitis_nares_normal_right"] == "on") {
 156     echo "checked";
 157                                                               };?>><span class=text></span><br />
 158 <td align="right"><?php echo xlt('Left:'); ?>  </td>
 159 <td><input type=checkbox name="bronchitis_nares_normal_left" <?php if ($obj["bronchitis_nares_normal_left"] == "on") {
 160     echo "checked";
 161                                                              };?>><span class=text></span><br />
 162 </tr>
 163
 164 <tr>
 165 <td width="60"></td>
 166 <td align="right"> <?php echo xlt('Thickened Right:'); ?> </td>
 167 <td><input type=checkbox name="bronchitis_tms_thickened_right" <?php if ($obj["bronchitis_tms_thickened_right"] == "on") {
 168     echo "checked";
 169                                                                };?>><span class=text></span><br />
 170 <td align="right"><?php echo xlt('Left:'); ?> </td>
 171 <td><input type=checkbox name="bronchitis_tms_thickened_left" <?php if ($obj["bronchitis_tms_thickened_left"] == "on") {
 172     echo "checked";
 173                                                               };?>><span class=text></span><br />
 174
 175 <td align="right"><?php echo xlt('Swelling Right'); ?> </td>
 176 <td><input type=checkbox name="bronchitis_nares_swelling_right" <?php if ($obj["bronchitis_nares_swelling_right"] == "on") {
 177     echo "checked";
 178                                                                 };?>><span class=text></span><br />
 179 <td align="right"><?php echo xlt('Left: '); ?> </td>
 180 <td><input type=checkbox name="bronchitis_nares_swelling_left" <?php if ($obj["bronchitis_nares_swelling_left"] == "on") {
 181     echo "checked";
 182                                                                };?>><span class=text></span><br />
 183 </tr>
 184
 185 <tr>
 186 <td width="60"></td>
 187 <td align="right"><?php echo xlt('A/F Level Right:'); ?> </td>
 188 <td><input type=checkbox name="bronchitis_tms_af_level_right" <?php if ($obj["bronchitis_tms_af_level_right"] == "on") {
 189     echo "checked";
 190                                                               };?>><span class=text></span><br />
 191 <td align="right"><?php echo xlt('Left:'); ?> </td>
 192 <td><input type=checkbox name="bronchitis_tms_af_level_left" <?php if ($obj["bronchitis_tms_af_level_left"] == "on") {
 193     echo "checked";
 194                                                              };?>><span class=text></span><br />
 195
 196 <td align="right"><?php echo xlt('Discharge Right'); ?> </td>
 197 <td><input type=checkbox name="bronchitis_nares_discharge_right" <?php if ($obj["bronchitis_nares_discharge_right"] == "on") {
 198     echo "checked";
 199                                                                  };?>><span class=text></span><br />
 200 <td align="right"><?php echo xlt('Left: '); ?> </td>
 201 <td><input type=checkbox name="bronchitis_nares_discharge_left" <?php if ($obj["bronchitis_nares_discharge_left"] == "on") {
 202     echo "checked";
 203                                                                 };?>><span class=text></span><br />
 204 </tr>
 205
 206 <tr>
 207 <td width="60"></td>
 208 <td align="right"><?php echo xlt('Retracted Right:'); ?> </td>
 209 <td><input type=checkbox name="bronchitis_tms_retracted_right" <?php if ($obj["bronchitis_tms_retracted_right"] == "on") {
 210     echo "checked";
 211                                                                };?>><span class=text></span><br />
 212 <td align="right"><?php echo xlt('Left:'); ?> </td>
 213 <td><input type=checkbox name="bronchitis_tms_retracted_left" <?php if ($obj["bronchitis_tms_retracted_left"] == "on") {
 214     echo "checked";
 215                                                               };?>><span class=text></span><br />
 216 </tr>
 217
 218 <tr>
 219 <td width="60"></td>
 220 <td align="right"><?php echo xlt('Bulging Right:'); ?> </td>
 221 <td><input type=checkbox name="bronchitis_tms_bulging_right" <?php if ($obj["bronchitis_tms_bulging_right"] == "on") {
 222     echo "checked";
 223                                                              };?>><span class=text></span><br />
 224 <td align="right"><?php echo xlt('Left:'); ?> </td>
 225 <td><input type=checkbox name="bronchitis_tms_bulging_left" <?php if ($obj["bronchitis_tms_bulging_left"] == "on") {
 226     echo "checked";
 227                                                             };?>><span class=text></span><br />
 228 </tr>
 229
 230 <tr>
 231 <td width="60"></td>
 232 <td align="right"><?php echo xlt('Perforated Right:'); ?> </td>
 233 <td><input type=checkbox name="bronchitis_tms_perforated_right" <?php if ($obj["bronchitis_tms_perforated_right"] == "on") {
 234     echo "checked";
 235                                                                 };?>><span class=text></span><br />
 236 <td align="right"><?php echo xlt('Left:'); ?> </td>
 237 <td><input type=checkbox name="bronchitis_tms_perforated_left" <?php if ($obj["bronchitis_tms_perforated_left"] == "on") {
 238     echo "checked";
 239                                                                };?>><span class=text></span><br />
 240 </tr>
 241 </table>
 242
 243 <table><tr>
 244 <td width="127"></td>
 245 <td align="right"><?php echo xlt('Not Examined:'); ?> </td>
 246 <td><input type=checkbox name="bronchitis_tms_nares_not_examined" <?php if ($obj["bronchitis_tms_nares_not_examined"] == "on") {
 247     echo "checked";
 248                                                                   };?>><span class=text></span><br />
 249 </tr></table>
 250 <br /><br />
 251
 252 <table>
 253 <tr>
 254 <td width="90"><?php echo xlt('SINUS TENDERNESS:'); ?> </td>
 255 <td align="right"><?php echo xlt('No Sinus Tenderness:'); ?> </td>
 256 <td><input type=checkbox name="bronchitis_no_sinus_tenderness" <?php if ($obj["bronchitis_no_sinus_tenderness"] == "on") {
 257     echo "checked";
 258                                                                };?>><span class=text></span><br />
 259 <td width="90"><?php echo xlt('OROPHARYNX: '); ?> </td>
 260 <td align="right"><?php echo xlt('Normal Oropharynx:'); ?> </td>
 261 <td><input type=checkbox name="bronchitis_oropharynx_normal"<?php if ($obj["bronchitis_oropharynx_normal"] == "on") {
 262     echo "checked";
 263                                                             };?>><span class=text></span><br />
 264 </tr>
 265
 266 <tr>
 267 <td width="90" align="right"><?php echo xlt('Frontal Right:'); ?>  </td>
 268 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_right" <?php if ($obj["bronchitis_sinus_tenderness_frontal_right"] == "on") {
 269     echo "checked";
 270                                                                           };?>><span class=text></span><br />
 271 <td align="right"><?php echo xlt('Left:'); ?> </td>
 272 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_left" <?php if ($obj["bronchitis_sinus_tenderness_frontal_left"] == "on") {
 273     echo "checked";
 274                                                                          };?>><span class=text></span><br />
 275 <td align="right"><?php echo xlt('Erythema:'); ?> </td>
 276 <td><input type=checkbox name="bronchitis_oropharynx_erythema" <?php if ($obj["bronchitis_oropharynx_erythema"] == "on") {
 277     echo "checked";
 278                                                                };?>><span class=text></span><br />
 279 <td align="right"><?php echo xlt('Exudate:'); ?> </td>
 280 <td><input type=checkbox name="bronchitis_oropharynx_exudate" <?php if ($obj["bronchitis_oropharynx_exudate"] == "on") {
 281     echo "checked";
 282                                                               };?>><span class=text></span><br />
 283 <td align="right"><?php echo xlt('Abcess:'); ?> </td>
 284 <td><input type=checkbox name="bronchitis_oropharynx_abcess" <?php if ($obj["bronchitis_oropharynx_abcess"] == "on") {
 285     echo "checked";
 286                                                              };?>><span class=text></span><br />
 287 <td align="right"><?php echo xlt('Ulcers:'); ?> </td>
 288 <td><input type=checkbox name="bronchitis_oropharynx_ulcers" <?php if ($obj["bronchitis_oropharynx_ulcers"] == "on") {
 289     echo "checked";
 290                                                              };?>><span class=text></span><br />
 291 </tr>
 292
 293 <tr>
 294 <td width ="90" align="right"><?php echo xlt('Maxillary Right:'); ?> </td>
 295 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_right" <?php if ($obj["bronchitis_sinus_tenderness_maxillary_right"] == "on") {
 296     echo "checked";
 297                                                                             };?>><span class=text></span><br /></td>
 298 <td align="right"><?php echo xlt('Left:'); ?> </td>
 299 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_left" <?php if ($obj["bronchitis_sinus_tenderness_maxillary_left"] == "on") {
 300     echo "checked";
 301                                                                            };?>><span class=text></span><br /></td>
 302 <td width="130" align="right"><?php echo xlt('Appearance:'); ?>  <span class="text"></span></td>
 303 <td><input type="text" name="bronchitis_oropharynx_appearance" value="<?php echo
 304 stripslashes($obj["bronchitis_oropharynx_appearance"]);?>" size="15"></td>
 305 </tr>
 306 </table>
 307
 308 <table>
 309 <tr>
 310 <td width="256" align="right"><?php echo xlt('Not Examined:'); ?>  </td>
 311 <td><input type=checkbox name="bronchitis_sinus_tenderness_not_examined" <?php if ($obj["bronchitis_sinus_tenderness_not_examined"] == "on") {
 312     echo "checked";
 313                                                                          };?>><span class=text></span><br />
 314 <td width="208" align="right"><?php echo xlt('Not Examined:'); ?>  </td>
 315 <td><input type=checkbox name="bronchitis_oropharynx_not_examined" <?php if ($obj["bronchitis_oropharynx_not_examined"] == "on") {
 316     echo "checked";
 317                                                                    };?>><span class=text></span><br />
 318 </tr>
 319 </table>
 320 <br /><br />
 321
 322 <table>
 323 <tr>
 324 <td width="60"><?php echo xlt('HEART:'); ?> </td>
 325 <td align="right"><?php echo xlt('laterally displaced PMI:'); ?> </td>
 326 <td><input type=checkbox name="bronchitis_heart_pmi" <?php if ($obj["bronchitis_heart_pmi"] == "on") {
 327     echo "checked";
 328                                                      };?>><span class=text></span><br />
 329 <td align="right"><?php echo xlt('S3:'); ?> </td>
 330 <td><input type=checkbox name="bronchitis_heart_s3" <?php if ($obj["bronchitis_heart_s3"] == "on") {
 331     echo "checked";
 332                                                     };?>><span class=text></span><br />
 333 <td align="right"><?php echo xlt('S4:'); ?> </td>
 334 <td><input type=checkbox name="bronchitis_heart_s4" <?php if ($obj["bronchitis_heart_s4"] == "on") {
 335     echo "checked";
 336                                                     };?>><span class=text></span><br />
 337 </tr>
 338
 339 <tr>
 340 <td width="60"></td>
 341 <td align="right"><?php echo xlt('Click:'); ?> </td>
 342 <td><input type=checkbox name="bronchitis_heart_click" <?php if ($obj["bronchitis_heart_click"] == "on") {
 343     echo "checked";
 344                                                        };?>><span class=text></span><br />
 345 <td align="right"><?php echo xlt('Rub:'); ?> </td>
 346 <td><input type=checkbox name="bronchitis_heart_rub" <?php if ($obj["bronchitis_heart_rub"] == "on") {
 347     echo "checked";
 348                                                      };?>><span class=text></span><br />
 349 </tr>
 350 </table>
 351
 352 <table><tr>
 353 <td width="200" align="right"><?php echo xlt('Murmur:'); ?>  <span class="text"></span></td>
 354 <td><input type="text" name="bronchitis_heart_murmur" value="<?php echo
 355 attr($obj["bronchitis_heart_murmur"]); ?>" size="15"></td>
 356
 357 <td><span class="text"><?php echo xlt('Grade:'); ?>  </span></td><td>
 358 <input type="text" name="bronchitis_heart_grade" value="<?php echo
 359 attr($obj["bronchitis_heart_grade"]); ?>" size="15"></td>
 360
 361 <td><span class="text"><?php echo xlt('Location:'); ?>  </span></td><td>
 362 <input type="text" name="bronchitis_heart_location" value="<?php echo
 363 attr($obj["bronchitis_heart_location"]); ?>" size="15"></td>
 364 </tr>
 365 </table>
 366
 367 <table><tr>
 368 <td width="205" align="right"><?php echo xlt('Normal Cardiac Exam:'); ?>  </td>
 369 <td><input type=checkbox name="bronchitis_heart_normal" <?php if ($obj["bronchitis_heart_normal"] == "on") {
 370     echo "checked";
 371                                                         };?>><span class=text></span><br />
 372 <td width="95" align="right"><?php echo xlt('Not Examined:'); ?>  </td>
 373 <td><input type=checkbox name="bronchitis_heart_not_examined" <?php if ($obj["bronchitis_heart_not_examined"] == "on") {
 374     echo "checked";
 375                                                               };?>><span class=text></span><br />
 376 </tr></table>
 377 <br /><br />
 378
 379 <table><tr>
 380 <td width="60"><?php echo xlt('Lungs:'); ?> </td>
 381 <td width="106"><?php echo xlt('Breath Sounds:'); ?> </td>
 382 <td align="right"> <?php echo xlt('normal:'); ?> </td>
 383 <td><input type=checkbox name="bronchitis_lungs_bs_normal" <?php if ($obj["bronchitis_lungs_bs_normal"] == "on") {
 384     echo "checked";
 385                                                            };?>><span class=text></span><br />
 386
 387 <td align="right"><?php echo xlt('reduced:'); ?> </td>
 388 <td><input type=checkbox name="bronchitis_lungs_bs_reduced" <?php if ($obj["bronchitis_lungs_bs_reduced"] == "on") {
 389     echo "checked";
 390                                                             };?>><span class=text></span><br />
 391
 392 <td align="right"><?php echo xlt('increased:'); ?> </td>
 393 <td><input type=checkbox name="bronchitis_lungs_bs_increased" <?php if ($obj["bronchitis_lungs_bs_increased"] == "on") {
 394     echo "checked";
 395                                                               };?>><span class=text></span><br />
 396 </tr>
 397
 398 <tr>
 399 <td width="60"></td>
 400 <td><?php echo xlt('Crackles:'); ?> </td>
 401 <td align="right"><?php echo xlt(' LLL:'); ?> </td>
 402 <td><input type=checkbox name="bronchitis_lungs_crackles_lll" <?php if ($obj["bronchitis_lungs_crackles_lll"] == "on") {
 403     echo "checked";
 404                                                               };?>><span class=text></span><br />
 405
 406 <td align="right"><?php echo xlt('RLL:'); ?> </td>
 407 <td><input type=checkbox name="bronchitis_lungs_crackles_rll" <?php if ($obj["bronchitis_lungs_crackles_rll"] == "on") {
 408     echo "checked";
 409                                                               };?>><span class=text></span><br />
 410
 411 <td align="right"><?php echo xlt('Bilateral:'); ?> </td>
 412 <td><input type=checkbox name="bronchitis_lungs_crackles_bll" <?php if ($obj["bronchitis_lungs_crackles_bll"] == "on") {
 413     echo "checked";
 414                                                               };?>><span class=text></span><br />
 415 </tr>
 416
 417 <tr>
 418 <td width="60"></td>
 419 <td><?php echo xlt('Rubs:'); ?> </td>
 420 <td align="right"><?php echo xlt('LLL:'); ?> </td>
 421 <td><input type=checkbox name="bronchitis_lungs_rubs_lll" <?php if ($obj["bronchitis_lungs_rubs_lll"] == "on") {
 422     echo "checked";
 423                                                           };?>><span class=text></span><br />
 424
 425 <td align="right"><?php echo xlt('RLL:'); ?> </td>
 426 <td><input type=checkbox name="bronchitis_lungs_rubs_rll" <?php if ($obj["bronchitis_lungs_rubs_rll"] == "on") {
 427     echo "checked";
 428                                                           };?>><span class=text></span><br />
 429
 430 <td align="right"><?php echo xlt('Bilateral:'); ?> </td>
 431 <td><input type=checkbox name="bronchitis_lungs_rubs_bll" <?php if ($obj["bronchitis_lungs_rubs_bll"] == "on") {
 432     echo "checked";
 433                                                           };?>><span class=text></span><br />
 434 </tr>
 435
 436 <tr>
 437 <td width="60"></td>
 438 <td><?php echo xlt('Wheezes:'); ?> </td>
 439 <td align="right"><?php echo xlt('LLL:'); ?> </td>
 440 <td><input type=checkbox name="bronchitis_lungs_wheezes_lll" <?php if ($obj["bronchitis_lungs_wheezes_lll"] == "on") {
 441     echo "checked";
 442                                                              };?>><span class=text></span><br />
 443
 444 <td align="right"><?php echo xlt('RLL:'); ?> </td>
 445 <td><input type=checkbox name="bronchitis_lungs_wheezes_rll" <?php if ($obj["bronchitis_lungs_wheezes_rll"] == "on") {
 446     echo "checked";
 447                                                              };?>><span class=text></span><br />
 448
 449 <td align="right"><?php echo xlt('Bilateral:'); ?> </td>
 450 <td><input type=checkbox name="bronchitis_lungs_wheezes_bll" <?php if ($obj["bronchitis_lungs_wheezes_bll"] == "on") {
 451     echo "checked";
 452                                                              };?>><span class=text></span><br />
 453
 454 <td align="right"><?php echo xlt('Diffuse:'); ?> </td>
 455 <td><input type=checkbox name="bronchitis_lungs_wheezes_dll" <?php if ($obj["bronchitis_lungs_wheezes_dll"] == "on") {
 456     echo "checked";
 457                                                              };?>><span class=text></span><br />
 458 </tr>
 459 </table>
 460
 461
 462 <table><tr>
 463 <td width="218" align="right"><?php echo xlt('Normal Lung Exam:'); ?>  </td>
 464 <td><input type=checkbox name="bronchitis_lungs_normal_exam" <?php if ($obj["bronchitis_lungs_normal_exam"] == "on") {
 465     echo "checked";
 466                                                              };?>><span class=text></span><br />
 467 <td width="140" align="right"><?php echo xlt('Not Examined'); ?> </td>
 468 <td><input type=checkbox name="bronchitis_lungs_not_examined" <?php if ($obj["bronchitis_lungs_not_examined"] == "on") {
 469     echo "checked";
 470                                                               };?>><span class=text></span><br />
 471 </tr></table>
 472 <br /><br />
 473
 474 <span class="text"><?php echo xlt('Diagnostic Tests:'); ?> </span><br />
 475 <textarea name="bronchitis_diagnostic_tests" cols ="67" rows="4"  wrap="virtual name">
 476 <?php echo text($obj["bronchitis_diagnostic_tests"]);?></textarea>
 477 <br /><br />
 478
 479 <table><tr>
 480 <span class="text"><?php echo xlt('Diagnosis: '); ?> </span>
 481 <br /><input type="text" name="diagnosis1_bronchitis_form" value="<?php echo
 482 attr($obj["diagnosis1_bronchitis_form"]);?>" size="40"><br />
 483 </tr>
 484
 485 <tr>
 486 <input type="text" name="diagnosis2_bronchitis_form" value="<?php echo
 487 attr($obj["diagnosis2_bronchitis_form"]);?>" size="40"><br />
 488 </tr>
 489
 490 <tr>
 491 <input type="text" name="diagnosis3_bronchitis_form" value="<?php echo
 492 attr($obj["diagnosis3_bronchitis_form"]);?>" size="40"><br />
 493 </tr>
 494
 495 <tr>
 496 <input type="text" name="diagnosis4_bronchitis_form" value="<?php echo
 497 attr($obj["diagnosis4_bronchitis_form"]);?>" size="40"><br />
 498 </tr>
 499
 500 <table>
 501 <br />
 502 <span class="text"><?php echo xlt('Additional Diagnosis:'); ?>  </span><br />
 503 <textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name">
 504 <?php echo text($obj["bronchitis_additional_diagnosis"]);?></textarea>
 505 <br /><br />
 506
 507 <span class="text"><?php echo xlt('Treatment: '); ?> </span><br />
 508 <textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name">
 509 <?php echo text($obj["bronchitis_treatment"]);?></textarea>
 510 <br />
 511
 512 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php echo xlt('Save'); ?> ]</a>
 513 <br />
 514 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
 515  onclick="top.restoreSession()">[<?php echo xlt('Don\'t Save Changes'); ?> ]</a>
 516
 517 </form>
 518 <?php
 519 formFooter();
 520 ?>