interface/forms/bronchitis/view.php

   1 <?php
   2 /**
   3  * Generated DocBlock
   4  *
   5  * @package OpenEMR
   6  * @link    http://www.open-emr.org
   7  * @author  cfapress <cfapress>
   8  * @author  Robert Down <robertdown@live.com>
   9  * @author  Brady Miller <brady.g.miller@gmail.com>
  10  * @copyright Copyright (c) 2008 cfapress <cfapress>
  11  * @copyright Copyright (c) 2017 Robert Down <robertdown@live.com>
  12  * @copyright Copyright (c) 2016 Brady Miller <brady.g.miller@gmail.com>
  13  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  14  */
  15 ?>
  16 <!-- Form created by Nikolai Vitsyn by 2004/01/23 -->
  17 <?php
  18 include_once("../../globals.php");
  19 $returnurl = 'encounter_top.php';
  20 ?>
  21 <html><head>
  22 <?php html_header_show();?>
  23 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  24 </head>
  25 <body class="body_top">
  26 <?php
  27 include_once("$srcdir/api.inc");
  28 $obj = formFetch("form_bronchitis", $_GET["id"]);
  29 ?>
  30 <form method=post action="<?php echo $rootdir?>/forms/bronchitis/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  31 <span class="title"><?php xl('Bronchitis Form', 'e'); ?></span><br><br>
  32
  33 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save', 'e'); ?>]</a>
  34 <br>
  35 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link"
  36  onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes', 'e'); ?>]</a>
  37 <br></br>
  38
  39 <span class=text><?php xl('Onset of Ilness: ', 'e'); ?></span><input type=entry name="bronchitis_date_of_illness" value="<?php echo stripslashes($obj{"bronchitis_date_of_illness"});?>" ><br></br>
  40
  41 <span class=text><?php xl('HPI:', 'e'); ?> </span><br><textarea cols=67 rows=8 wrap=virtual name="bronchitis_hpi" ><?php echo stripslashes($obj{"bronchitis_hpi"});?></textarea><br></br>
  42
  43
  44 <table><th colspan="5">"<?php xl('Other Pertinent Symptoms', 'e'); ?> ":</th>
  45 <tr>
  46 <td width="60" align="right"><?php xl('Fever:', 'e'); ?> </td>
  47 <td><input type=checkbox name="bronchitis_ops_fever" <?php if ($obj{"bronchitis_ops_fever"} == "on") {
  48     echo "checked";
  49 };?>><span class=text></span><br>
  50
  51 <td width="140" align="right"><?php xl('Cough:', 'e'); ?> </td>
  52 <td><input type=checkbox name="bronchitis_ops_cough" <?php if ($obj{"bronchitis_ops_cough"} == "on") {
  53     echo "checked";
  54 };?>><span class=text></span><br>
  55
  56 <td width="170" align="right"><?php xl('Dizziness:', 'e'); ?> </td>
  57 <td><input type=checkbox name="bronchitis_ops_dizziness" <?php if ($obj{"bronchitis_ops_dizziness"} == "on") {
  58     echo "checked";
  59 };?>><span class=text></span><br>
  60 </tr>
  61
  62 <tr>
  63 <td width="60" align="right"><?php xl('Chest Pain:', 'e'); ?> </td>
  64 <td><input type=checkbox name="bronchitis_ops_chest_pain" <?php if ($obj{"bronchitis_ops_chest_pain"} == "on") {
  65     echo "checked";
  66 };?>><span class=text></span><br>
  67 <td width="130" align="right"><?php xl('Dyspnea:', 'e'); ?> </td>
  68 <td><input type=checkbox name="bronchitis_ops_dyspnea" <?php if ($obj{"bronchitis_ops_dyspnea"} == "on") {
  69     echo "checked";
  70 };?>><span class=text></span><br>
  71 <td width="180" align="right"><?php xl('Sweating:', 'e'); ?> </td>
  72 <td><input type=checkbox name="bronchitis_ops_sweating" <?php if ($obj{"bronchitis_ops_sweating"} == "on") {
  73     echo "checked";
  74 };?>><span class=text></span><br>
  75 </tr>
  76
  77 <tr>
  78 <td width="60" align="right"><?php xl('Wheezing:', 'e'); ?> </td>
  79 <td><input type=checkbox name="bronchitis_ops_wheezing" <?php if ($obj{"bronchitis_ops_wheezing"} == "on") {
  80     echo "checked";
  81 };?>><span class=text></span><br>
  82
  83 <td width="130" align="right"><?php xl('Malaise:', 'e'); ?> </td>
  84 <td><input type=checkbox name="bronchitis_ops_malaise" <?php if ($obj{"bronchitis_ops_malaise"} == "on") {
  85     echo "checked";
  86 };?>><span class=text></span><br>
  87 </tr>
  88
  89 <tr>
  90 <td width="60" align="right"><?php xl('Sputum:', 'e'); ?> </td>
  91 <td><input type=checkbox name="bronchitis_ops_sputum" <?php if ($obj{"bronchitis_ops_sputum"} == "on") {
  92     echo "checked";
  93 };?>><span class=text></span><br></td>
  94
  95 <td width="130" align="right"><?php xl('Appearance:', 'e'); ?>  <span class="text"></span></td>
  96 <td><input type=entry name="bronchitis_ops_appearance" value="<?php echo
  97 stripslashes($obj{"bronchitis_ops_appearance"});?>" size="15"></td>
  98 </tr>
  99 </table>
 100
 101 <table><tr>
 102 <td width="227" align="right"><?php xl('All Reviewed and Negative:', 'e'); ?> </td>
 103 <td><input type=checkbox name="bronchitis_ops_all_reviewed" <?php if ($obj{"bronchitis_ops_all_reviewed"} == "on") {
 104     echo "checked";
 105 };?>><span class=text></span><br>
 106 </tr>
 107 </table>
 108 <br></br>
 109
 110 <table >
 111 <tr>
 112 <td width="60" align="right"><?php xl('Review of PMH:', 'e'); ?> </td>
 113 <td><input type=checkbox name="bronchitis_review_of_pmh" <?php if ($obj{"bronchitis_review_of_pmh"} == "on") {
 114     echo "checked";
 115 };?>><span class=text></span><br></td>
 116 <td align="right"><?php xl('Medications:', 'e'); ?> </td>
 117 <td><input type=checkbox name="bronchitis_review_of_medications" <?php if ($obj{"bronchitis_review_of_medications"} == "on") {
 118     echo "checked";
 119 };?>><span class=text></span><br></td>
 120 <td align="right"><?php xl('Allergies:', 'e'); ?> </td>
 121 <td><input type=checkbox name="bronchitis_review_of_allergies" <?php if ($obj{"bronchitis_review_of_allergies"} == "on") {
 122     echo "checked";
 123 };?>><span class=text></span><br></td>
 124 <td align="right"><?php xl('Social History:', 'e'); ?> </td>
 125 <td><input type=checkbox name="bronchitis_review_of_sh" <?php if ($obj{"bronchitis_review_of_sh"} == "on") {
 126     echo "checked";
 127 };?>><span class=text></span><br></td>
 128 <td align="right"><?php xl('Family History:', 'e'); ?> </td>
 129 <td><input type=checkbox name="bronchitis_review_of_fh" <?php if ($obj{"bronchitis_review_of_fh"} == "on") {
 130     echo "checked";
 131 };?>><span class=text></span><br></td>
 132 </tr>
 133 </table>
 134 <br></br>
 135
 136
 137 <table>
 138 <tr>
 139 <td width="60"><?php xl('TM\'S:', 'e'); ?> </td>
 140 <td align="right"><?php xl('Normal Right:', 'e'); ?> </td>
 141 <td><input type=checkbox name="bronchitis_tms_normal_right" <?php if ($obj{"bronchitis_tms_normal_right"} == "on") {
 142     echo "checked";
 143 };?>><span class=text></span><br>
 144 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 145 <td><input type=checkbox name="bronchitis_tms_normal_left" <?php if ($obj{"bronchitis_tms_normal_left"} == "on") {
 146     echo "checked";
 147 };?>><span class=text></span><br>
 148 <td align="right"><?php xl('NARES: Normal Right', 'e'); ?> </td>
 149 <td><input type=checkbox name="bronchitis_nares_normal_right" <?php if ($obj{"bronchitis_nares_normal_right"} == "on") {
 150     echo "checked";
 151 };?>><span class=text></span><br>
 152 <td align="right"><?php xl('Left:', 'e'); ?>  </td>
 153 <td><input type=checkbox name="bronchitis_nares_normal_left" <?php if ($obj{"bronchitis_nares_normal_left"} == "on") {
 154     echo "checked";
 155 };?>><span class=text></span><br>
 156 </tr>
 157
 158 <tr>
 159 <td width="60"></td>
 160 <td align="right"> <?php xl('Thickened Right:', 'e'); ?> </td>
 161 <td><input type=checkbox name="bronchitis_tms_thickened_right" <?php if ($obj{"bronchitis_tms_thickened_right"} == "on") {
 162     echo "checked";
 163 };?>><span class=text></span><br>
 164 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 165 <td><input type=checkbox name="bronchitis_tms_thickened_left" <?php if ($obj{"bronchitis_tms_thickened_left"} == "on") {
 166     echo "checked";
 167 };?>><span class=text></span><br>
 168
 169 <td align="right"><?php xl('Swelling Right', 'e'); ?> </td>
 170 <td><input type=checkbox name="bronchitis_nares_swelling_right" <?php if ($obj{"bronchitis_nares_swelling_right"} == "on") {
 171     echo "checked";
 172 };?>><span class=text></span><br>
 173 <td align="right"><?php xl('Left: ', 'e'); ?> </td>
 174 <td><input type=checkbox name="bronchitis_nares_swelling_left" <?php if ($obj{"bronchitis_nares_swelling_left"} == "on") {
 175     echo "checked";
 176 };?>><span class=text></span><br>
 177 </tr>
 178
 179 <tr>
 180 <td width="60"></td>
 181 <td align="right"><?php xl('A/F Level Right:', 'e'); ?> </td>
 182 <td><input type=checkbox name="bronchitis_tms_af_level_right" <?php if ($obj{"bronchitis_tms_af_level_right"} == "on") {
 183     echo "checked";
 184 };?>><span class=text></span><br>
 185 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 186 <td><input type=checkbox name="bronchitis_tms_af_level_left" <?php if ($obj{"bronchitis_tms_af_level_left"} == "on") {
 187     echo "checked";
 188 };?>><span class=text></span><br>
 189
 190 <td align="right"><?php xl('Discharge Right', 'e'); ?> </td>
 191 <td><input type=checkbox name="bronchitis_nares_discharge_right" <?php if ($obj{"bronchitis_nares_discharge_right"} == "on") {
 192     echo "checked";
 193 };?>><span class=text></span><br>
 194 <td align="right"><?php xl('Left: ', 'e'); ?> </td>
 195 <td><input type=checkbox name="bronchitis_nares_discharge_left" <?php if ($obj{"bronchitis_nares_discharge_left"} == "on") {
 196     echo "checked";
 197 };?>><span class=text></span><br>
 198 </tr>
 199
 200 <tr>
 201 <td width="60"></td>
 202 <td align="right"><?php xl('Retracted Right:', 'e'); ?> </td>
 203 <td><input type=checkbox name="bronchitis_tms_retracted_right" <?php if ($obj{"bronchitis_tms_retracted_right"} == "on") {
 204     echo "checked";
 205 };?>><span class=text></span><br>
 206 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 207 <td><input type=checkbox name="bronchitis_tms_retracted_left" <?php if ($obj{"bronchitis_tms_retracted_left"} == "on") {
 208     echo "checked";
 209 };?>><span class=text></span><br>
 210 </tr>
 211
 212 <tr>
 213 <td width="60"></td>
 214 <td align="right"><?php xl('Bulging Right:', 'e'); ?> </td>
 215 <td><input type=checkbox name="bronchitis_tms_bulging_right" <?php if ($obj{"bronchitis_tms_bulging_right"} == "on") {
 216     echo "checked";
 217 };?>><span class=text></span><br>
 218 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 219 <td><input type=checkbox name="bronchitis_tms_bulging_left" <?php if ($obj{"bronchitis_tms_bulging_left"} == "on") {
 220     echo "checked";
 221 };?>><span class=text></span><br>
 222 </tr>
 223
 224 <tr>
 225 <td width="60"></td>
 226 <td align="right"><?php xl('Perforated Right:', 'e'); ?> </td>
 227 <td><input type=checkbox name="bronchitis_tms_perforated_right" <?php if ($obj{"bronchitis_tms_perforated_right"} == "on") {
 228     echo "checked";
 229 };?>><span class=text></span><br>
 230 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 231 <td><input type=checkbox name="bronchitis_tms_perforated_left" <?php if ($obj{"bronchitis_tms_perforated_left"} == "on") {
 232     echo "checked";
 233 };?>><span class=text></span><br>
 234 </tr>
 235 </table>
 236
 237 <table><tr>
 238 <td width="127"></td>
 239 <td align="right"><?php xl('Not Examined:', 'e'); ?> </td>
 240 <td><input type=checkbox name="bronchitis_tms_nares_not_examined" <?php if ($obj{"bronchitis_tms_nares_not_examined"} == "on") {
 241     echo "checked";
 242 };?>><span class=text></span><br>
 243 </tr></table>
 244 <br></br>
 245
 246 <table>
 247 <tr>
 248 <td width="90"><?php xl('SINUS TENDERNESS:', 'e'); ?> </td>
 249 <td align="right"><?php xl('No Sinus Tenderness:', 'e'); ?> </td>
 250 <td><input type=checkbox name="bronchitis_no_sinus_tenderness" <?php if ($obj{"bronchitis_no_sinus_tenderness"} == "on") {
 251     echo "checked";
 252 };?>><span class=text></span><br>
 253 <td width="90"><?php xl('OROPHARYNX: ', 'e'); ?> </td>
 254 <td align="right"><?php xl('Normal Oropharynx:', 'e'); ?> </td>
 255 <td><input type=checkbox name="bronchitis_oropharynx_normal"<?php if ($obj{"bronchitis_oropharynx_normal"} == "on") {
 256     echo "checked";
 257 };?>><span class=text></span><br>
 258 </tr>
 259
 260 <tr>
 261 <td width="90" align="right"><?php xl('Frontal Right:', 'e'); ?>  </td>
 262 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_right" <?php if ($obj{"bronchitis_sinus_tenderness_frontal_right"} == "on") {
 263     echo "checked";
 264 };?>><span class=text></span><br>
 265 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 266 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_left" <?php if ($obj{"bronchitis_sinus_tenderness_frontal_left"} == "on") {
 267     echo "checked";
 268 };?>><span class=text></span><br>
 269 <td align="right"><?php xl('Erythema:', 'e'); ?> </td>
 270 <td><input type=checkbox name="bronchitis_oropharynx_erythema" <?php if ($obj{"bronchitis_oropharynx_erythema"} == "on") {
 271     echo "checked";
 272 };?>><span class=text></span><br>
 273 <td align="right"><?php xl('Exudate:', 'e'); ?> </td>
 274 <td><input type=checkbox name="bronchitis_oropharynx_exudate" <?php if ($obj{"bronchitis_oropharynx_exudate"} == "on") {
 275     echo "checked";
 276 };?>><span class=text></span><br>
 277 <td align="right"><?php xl('Abcess:', 'e'); ?> </td>
 278 <td><input type=checkbox name="bronchitis_oropharynx_abcess" <?php if ($obj{"bronchitis_oropharynx_abcess"} == "on") {
 279     echo "checked";
 280 };?>><span class=text></span><br>
 281 <td align="right"><?php xl('Ulcers:', 'e'); ?> </td>
 282 <td><input type=checkbox name="bronchitis_oropharynx_ulcers" <?php if ($obj{"bronchitis_oropharynx_ulcers"} == "on") {
 283     echo "checked";
 284 };?>><span class=text></span><br>
 285 </tr>
 286
 287 <tr>
 288 <td width ="90" align="right"><?php xl('Maxillary Right:', 'e'); ?> </td>
 289 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_right" <?php if ($obj{"bronchitis_sinus_tenderness_maxillary_right"} == "on") {
 290     echo "checked";
 291 };?>><span class=text></span><br></td>
 292 <td align="right"><?php xl('Left:', 'e'); ?> </td>
 293 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_left" <?php if ($obj{"bronchitis_sinus_tenderness_maxillary_left"} == "on") {
 294     echo "checked";
 295 };?>><span class=text></span><br></td>
 296 <td width="130" align="right"><?php xl('Appearance:', 'e'); ?>  <span class="text"></span></td>
 297 <td><input type=entry name="bronchitis_oropharynx_appearance" value="<?php echo
 298 stripslashes($obj{"bronchitis_oropharynx_appearance"});?>" size="15"></td>
 299 </tr>
 300 </table>
 301
 302 <table>
 303 <tr>
 304 <td width="256" align="right"><?php xl('Not Examined:', 'e'); ?>  </td>
 305 <td><input type=checkbox name="bronchitis_sinus_tenderness_not_examined" <?php if ($obj{"bronchitis_sinus_tenderness_not_examined"} == "on") {
 306     echo "checked";
 307 };?>><span class=text></span><br>
 308 <td width="208" align="right"><?php xl('Not Examined:', 'e'); ?>  </td>
 309 <td><input type=checkbox name="bronchitis_oropharynx_not_examined" <?php if ($obj{"bronchitis_oropharynx_not_examined"} == "on") {
 310     echo "checked";
 311 };?>><span class=text></span><br>
 312 </tr>
 313 </table>
 314 <br></br>
 315
 316 <table>
 317 <tr>
 318 <td width="60"><?php xl('HEART:', 'e'); ?> </td>
 319 <td align="right"><?php xl('laterally displaced PMI:', 'e'); ?> </td>
 320 <td><input type=checkbox name="bronchitis_heart_pmi" <?php if ($obj{"bronchitis_heart_pmi"} == "on") {
 321     echo "checked";
 322 };?>><span class=text></span><br>
 323 <td align="right"><?php xl('S3:', 'e'); ?> </td>
 324 <td><input type=checkbox name="bronchitis_heart_s3" <?php if ($obj{"bronchitis_heart_s3"} == "on") {
 325     echo "checked";
 326 };?>><span class=text></span><br>
 327 <td align="right"><?php xl('S4:', 'e'); ?> </td>
 328 <td><input type=checkbox name="bronchitis_heart_s4" <?php if ($obj{"bronchitis_heart_s4"} == "on") {
 329     echo "checked";
 330 };?>><span class=text></span><br>
 331 </tr>
 332
 333 <tr>
 334 <td width="60"></td>
 335 <td align="right"><?php xl('Click:', 'e'); ?> </td>
 336 <td><input type=checkbox name="bronchitis_heart_click" <?php if ($obj{"bronchitis_heart_click"} == "on") {
 337     echo "checked";
 338 };?>><span class=text></span><br>
 339 <td align="right"><?php xl('Rub:', 'e'); ?> </td>
 340 <td><input type=checkbox name="bronchitis_heart_rub" <?php if ($obj{"bronchitis_heart_rub"} == "on") {
 341     echo "checked";
 342 };?>><span class=text></span><br>
 343 </tr>
 344 </table>
 345
 346 <table><tr>
 347 <td width="200" align="right"><?php xl('Murmur:', 'e'); ?>  <span class="text"></span></td>
 348 <td><input type=entry name="bronchitis_heart_murmur" value="<?php echo
 349 stripslashes($obj{"bronchitis_heart_murmur"});?>" size="15"></td>
 350
 351 <td><span class="text"><?php xl('Grade:', 'e'); ?>  </span></td><td>
 352 <input type=entry name="bronchitis_heart_grade" value="<?php echo
 353 stripslashes($obj{"bronchitis_heart_grade"});?>" size="15"></td>
 354
 355 <td><span class="text"><?php xl('Location:', 'e'); ?>  </span></td><td>
 356 <input type=entry name="bronchitis_heart_location" value="<?php echo
 357 stripslashes($obj{"bronchitis_heart_location"});?>" size="15"></td>
 358 </tr>
 359 </table>
 360
 361 <table><tr>
 362 <td width="205" align="right"><?php xl('Normal Cardiac Exam:', 'e'); ?>  </td>
 363 <td><input type=checkbox name="bronchitis_heart_normal" <?php if ($obj{"bronchitis_heart_normal"} == "on") {
 364     echo "checked";
 365 };?>><span class=text></span><br>
 366 <td width="95" align="right"><?php xl('Not Examined:', 'e'); ?>  </td>
 367 <td><input type=checkbox name="bronchitis_heart_not_examined" <?php if ($obj{"bronchitis_heart_not_examined"} == "on") {
 368     echo "checked";
 369 };?>><span class=text></span><br>
 370 </tr></table>
 371 <br></br>
 372
 373 <table><tr>
 374 <td width="60"><?php xl('Lungs:', 'e'); ?> </td>
 375 <td width="106"><?php xl('Breath Sounds:', 'e'); ?> </td>
 376 <td align="right"> <?php xl('normal:', 'e'); ?> </td>
 377 <td><input type=checkbox name="bronchitis_lungs_bs_normal" <?php if ($obj{"bronchitis_lungs_bs_normal"} == "on") {
 378     echo "checked";
 379 };?>><span class=text></span><br>
 380
 381 <td align="right"><?php xl('reduced:', 'e'); ?> </td>
 382 <td><input type=checkbox name="bronchitis_lungs_bs_reduced" <?php if ($obj{"bronchitis_lungs_bs_reduced"} == "on") {
 383     echo "checked";
 384 };?>><span class=text></span><br>
 385
 386 <td align="right"><?php xl('increased:', 'e'); ?> </td>
 387 <td><input type=checkbox name="bronchitis_lungs_bs_increased" <?php if ($obj{"bronchitis_lungs_bs_increased"} == "on") {
 388     echo "checked";
 389 };?>><span class=text></span><br>
 390 </tr>
 391
 392 <tr>
 393 <td width="60"></td>
 394 <td><?php xl('Crackles:', 'e'); ?> </td>
 395 <td align="right"><?php xl(' LLL:', 'e'); ?> </td>
 396 <td><input type=checkbox name="bronchitis_lungs_crackles_lll" <?php if ($obj{"bronchitis_lungs_crackles_lll"} == "on") {
 397     echo "checked";
 398 };?>><span class=text></span><br>
 399
 400 <td align="right"><?php xl('RLL:', 'e'); ?> </td>
 401 <td><input type=checkbox name="bronchitis_lungs_crackles_rll" <?php if ($obj{"bronchitis_lungs_crackles_rll"} == "on") {
 402     echo "checked";
 403 };?>><span class=text></span><br>
 404
 405 <td align="right"><?php xl('Bilateral:', 'e'); ?> </td>
 406 <td><input type=checkbox name="bronchitis_lungs_crackles_bll" <?php if ($obj{"bronchitis_lungs_crackles_bll"} == "on") {
 407     echo "checked";
 408 };?>><span class=text></span><br>
 409 </tr>
 410
 411 <tr>
 412 <td width="60"></td>
 413 <td><?php xl('Rubs:', 'e'); ?> </td>
 414 <td align="right"><?php xl('LLL:', 'e'); ?> </td>
 415 <td><input type=checkbox name="bronchitis_lungs_rubs_lll" <?php if ($obj{"bronchitis_lungs_rubs_lll"} == "on") {
 416     echo "checked";
 417 };?>><span class=text></span><br>
 418
 419 <td align="right"><?php xl('RLL:', 'e'); ?> </td>
 420 <td><input type=checkbox name="bronchitis_lungs_rubs_rll" <?php if ($obj{"bronchitis_lungs_rubs_rll"} == "on") {
 421     echo "checked";
 422 };?>><span class=text></span><br>
 423
 424 <td align="right"><?php xl('Bilateral:', 'e'); ?> </td>
 425 <td><input type=checkbox name="bronchitis_lungs_rubs_bll" <?php if ($obj{"bronchitis_lungs_rubs_bll"} == "on") {
 426     echo "checked";
 427 };?>><span class=text></span><br>
 428 </tr>
 429
 430 <tr>
 431 <td width="60"></td>
 432 <td><?php xl('Wheezes:', 'e'); ?> </td>
 433 <td align="right"><?php xl('LLL:', 'e'); ?> </td>
 434 <td><input type=checkbox name="bronchitis_lungs_wheezes_lll" <?php if ($obj{"bronchitis_lungs_wheezes_lll"} == "on") {
 435     echo "checked";
 436 };?>><span class=text></span><br>
 437
 438 <td align="right"><?php xl('RLL:', 'e'); ?> </td>
 439 <td><input type=checkbox name="bronchitis_lungs_wheezes_rll" <?php if ($obj{"bronchitis_lungs_wheezes_rll"} == "on") {
 440     echo "checked";
 441 };?>><span class=text></span><br>
 442
 443 <td align="right"><?php xl('Bilateral:', 'e'); ?> </td>
 444 <td><input type=checkbox name="bronchitis_lungs_wheezes_bll" <?php if ($obj{"bronchitis_lungs_wheezes_bll"} == "on") {
 445     echo "checked";
 446 };?>><span class=text></span><br>
 447
 448 <td align="right"><?php xl('Diffuse:', 'e'); ?> </td>
 449 <td><input type=checkbox name="bronchitis_lungs_wheezes_dll" <?php if ($obj{"bronchitis_lungs_wheezes_dll"} == "on") {
 450     echo "checked";
 451 };?>><span class=text></span><br>
 452 </tr>
 453 </table>
 454
 455
 456 <table><tr>
 457 <td width="218" align="right"><?php xl('Normal Lung Exam:', 'e'); ?>  </td>
 458 <td><input type=checkbox name="bronchitis_lungs_normal_exam" <?php if ($obj{"bronchitis_lungs_normal_exam"} == "on") {
 459     echo "checked";
 460 };?>><span class=text></span><br>
 461 <td width="140" align="right"><?php xl('Not Examined', 'e'); ?> </td>
 462 <td><input type=checkbox name="bronchitis_lungs_not_examined" <?php if ($obj{"bronchitis_lungs_not_examined"} == "on") {
 463     echo "checked";
 464 };?>><span class=text></span><br>
 465 </tr></table>
 466 <br></br>
 467
 468 <span class="text"><?php xl('Diagnostic Tests:', 'e'); ?> </span></br>
 469 <textarea name="bronchitis_diagnostic_tests" cols ="67" rows="4"  wrap="virtual name">
 470 <?php echo stripslashes($obj{"bronchitis_diagnostic_tests"});?></textarea>
 471 <br></br>
 472
 473 <table><tr>
 474 <span class="text"><?php xl('Diagnosis: ', 'e'); ?> </span>
 475 <br><input type=entry name="diagnosis1_bronchitis_form" value="<?php echo
 476 stripslashes($obj{"diagnosis1_bronchitis_form"});?>" size="40"><br>
 477 </tr>
 478
 479 <tr>
 480 <input type=entry name="diagnosis2_bronchitis_form" value="<?php echo
 481 stripslashes($obj{"diagnosis2_bronchitis_form"});?>" size="40"><br>
 482 </tr>
 483
 484 <tr>
 485 <input type=entry name="diagnosis3_bronchitis_form" value="<?php echo
 486 stripslashes($obj{"diagnosis3_bronchitis_form"});?>" size="40"><br>
 487 </tr>
 488
 489 <tr>
 490 <input type=entry name="diagnosis4_bronchitis_form" value="<?php echo
 491  stripslashes($obj{"diagnosis4_bronchitis_form"});?>" size="40"><br>
 492 </tr>
 493
 494 <table>
 495 <br>
 496 <span class="text"><?php xl('Additional Diagnosis:', 'e'); ?>  </span></br>
 497 <textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name">
 498 <?php echo stripslashes($obj{"bronchitis_additional_diagnosis"});?></textarea>
 499 <br></br>
 500
 501 <span class="text"><?php xl('Treatment: ', 'e'); ?> </span></br>
 502 <textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name">
 503 <?php echo stripslashes($obj{"bronchitis_treatment"});?></textarea>
 504 </br>
 505
 506 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save', 'e'); ?> ]</a>
 507 <br>
 508 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link"
 509  onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes', 'e'); ?> ]</a>
 510
 511 </form>
 512 <?php
 513 formFooter();
 514 ?>