form 1

[select name="variable_1" value="MR. |MS. "]
[text name="variable_1" default=""] 
IS A [select name="variable_1" value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"] YEAR OLD 
[select name="variable_1" value="MALE|FEMALE"]
WHO IS HOSPITAL DAY [select name="variable_1" value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30"]
FOR 
[select name="variable_1" value="
ACUTELY DECOMPONSATED ALCOHOLIC LIVER DISEASE|
ACUTELY DECOMPONSATED HEART FAILURE
"]

YESTERDAY
[select name="variable_1" value="HE |SHE "]

[select name="variable_1" value="
HAD MELENA WHICH MADE THE HEMOGLOBIN DROP DOWN TO 7|

"] 

SO WE 

[select name="variable_1" value="
x
|
Y
"] 

6.	GAVE 2 UNITES OF PRBCS
7.	WHICH MADE HER/// HIS HEMOGLOBIN GO FROM 7.5  UP TO 10
8.	OVERNIGHT
9.	SHE /// HE HAD A EPISODE OF AFIB WITH RVR 
10.	THAT REACHED A RATE OF 160
11.	SHE /// HE ALSO HAD BLOOD IN HIS STOOL.
12.	AND THE NURSE REPORTED BLOOD CLOTS IN HIS FOLLEY CATHETER 

13.	___________________________________________________________________________________________
14.	SUBJECTIVELY...........
15.	THIS MORNING SHE /// HE  COMPLAINS OF DISSIMINATED PAIN IN HIS JOINTS, BACK, AND HIS HEAD WHICH HE SAYS HEAD WAS THE WORSE
16.	SHE /// HE REPORTS HIS LAST BOWEL MOVEMENT WAS AT: ____________ AND WAS BLOODLY | NON BLOODY
17.	PATIENT ATTESTS TO FEVER, CHILLS, NAUSEA, VOMITING, 
18.	PATIENT DENIES  FEVER, CHILLS, NAUSEA, VOMITING
19.	___________________________________________________________________________________________
20.	OBJECTIVELY..............
21.	PAIENT'S VITALS SHOWED SHE /// HE  CONTINUES TO BE HEMODYNAMICALLY UN // STABLE & FEBRILE // AFEBRILE
22.	MAXIMUM TEMPERATURE _____ 97.7
23.	CURENT TEMPERATURE________ 97.7
24.	HEART RATE__________________98 BEATS PER MINUTE
25.	BLOOD PRESSRE ______________106 SYSTOLIC OVER 57 DIASTOLIC
26.	RESPIRATORY RATE ___________ 22 
27.	OXYGEN SATURATION__________92 ON [ROOM AIR/___ LITERS OF OXYGEN]]
28.	HIS 24 HOUR INS VERSUS OUT RATIO IS ____________ [ IN / OUT = X ]
29.	WITH A URINE OUTPUT OF____________[          ] ON THE MOST RECENT 8 HOUR SHIFT,
30.	WITH A URINE OUTPUT OF____________[          ] ON THE SHIFT BEFORE THAT, 
31.	FOR AN AVERAGE OF _________________[          ] PER SHIFT. 
32.	NG TUBE? 
33.	FOLLEY CATHETER IN PLACE. I DID SEE URINE | I DIDNT SEE URINE | I DID SEE CLOTS | I DIDNT SEE CLOTS
34.	JP DRAIN? 
35.	PACKED RBCS? 
36.	 CRYO?
37.	 FRESH FROZEN PLASMA? 
38.	PLATELETS
39.	___________________________________________________________________________________________
40.	ON PHYSICAL EXAM PATIENT________________________________________________________________
41.	APPEARED TO BE: SEEMS CHRONICALLY MALNOURISED | SEVERELY JAUNDICED | I DID/DID NOT SEE FASICULATIONS IN HIS TOUNGE
42.	[GENERAL EXAM - DOING WELL, IN NO ACUTE DISTRESS? | IN DISTRESS | Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
43.	HEAD APPEARS [normocephalic.]
44.	FUNDI APPEARED NORMAL
45.	VISION WAS [GROSSLY INTACT]
46.	CARDIOPULMONARY EXAM WAS REGULAR, 
47.	MONITOR SHOWED HE'S IN SINUS RYTHM, 
48.	REGULAR 
49.	AND I DID/DIDNT APPRECIATE JVD
50.	HEART WAS  [XXXX] LUNGS WERE LMONARY FINDINGS], 
51.	ABDOMINAL EXAM REVEALED DISTENDED DUE TO ASCITES, W OR W/O REBOUND. [ABDOMINAL FINDINGS]. 
52.	INCISIONS / DRESSINGS? CLEAN? DRY? IN TACT? 
53.	OSTOMY IS [COLOR, PATENCY, PROTUBERANT OR NOT, PRODUCTIVE OR NOT]
54.	AND AS WE SAID, FOLLEY CATHETER IN PLACE. 
55.	I DID SEE URINE | I DIDNT SEE URINE | I DID SEE CLOTS | I DIDNT SEE CLOTS
56.	VASCULAR EXAM REVEALS [VASCULAR FINDINGS IF PERTITINENT]
57.	ANY OTHER PPERTNENT EXAM FINDINGS  
58.	NEUROLOGIC EXAM REVEALED ASCITRICS / NO ASTERICTIS
59.	___________________________________________________________________________________________
60.	LABS DRAWN WERE:_______________________________________________________________
61.	LFTS ARE [ TRENDING UP / TRENDING DOWN / STABLE ]
62.	SERUM CREATITINE IS [ TRENDING UP / TRENDING DOWN / STABLE ]
63.	SODIUM IS [ TRENDING UP / TRENDING DOWN / STABLE ]
64.	POTASSIUM IS [ TRENDING UP / TRENDING DOWN / STABLE ]
65.	MAGNESIUM [ TRENDING UP / TRENDING DOWN / STABLE ] 
66.	WAS HIGH / LOW AT ____1.6____
67.	NOWHIGH / LOW  AT____
68.	CMP DRAWN FOR [INDICATION] SHOWED [FINDINGS]
69.	CBC DRAWN FOR INDICATION SHOWED [FINDINGS]
70.	HEMOGLOBIN ROSE DROPPED FROM __ 10 __ TO ___ 8 ___ THIS MORNING.
71.	HER /// HIS PLATELETS [XXXX]
72.	___________________________________________________________________________________________
73.	IMAGING STUDIES PERFORMED WERE:
74.	NEW ABDOMINAL ULTRASOUND TO:
75.	WHICH DEMONSTRATED SMALL AMOUNTS OF ASCITIES 
76.	QUANITIFY ASCITES
77.	MICRO
78.	BLOOD CULTURES SHOWED NO GROWTH TODAY @ 72 HOURS
79.	[XXXX] FOR [XXXXXXXX] SHOWED [XXXX]
80.	___________________________________________________________________________________________
81.	ASSESSMENT................
82.	PATIENT IS A
83.	 __68___ YEAR OLD FEMALE MALE
84.	HOSPITAL DAY NUMBER 4
85.	FOR ALCOHOLIC HEPATITIS & HEPATORENAL SYNDROME
86.	OF WHICH WE ARE TREATING 
87.	THE ALCOHOLIC HEPATITIS WITH PENTOXYPHILINE 
88.	AND THE HEPATORENAL SYNDROME WE ARE TREATING WITH OCTREOTIDE, MITODRINE, ALBUMIN.
89.	WHO'S __________ GENERALLY [IMPROVING | STABLE | DEVELOPING SHOCK |SEPTIC ] 
90.	PLAN IS FOR TODAY IS TO
91.	FIRST
92.	ADDRESS THE [XXXXXXX] BY [XXXXXXX]
93.	SECOND
94.	TO ADDRESS THE [XXXXXXX] BY [XXXXXXX]
95.	THIRD
96.	TO ADDRESS THE [XXXXXXX] BY [XXXXXXX]
97.	AND LASTLY
98.	TO ADDRESS THE [XXXXXXX] BY [XXXXXXX]
[checkbox name="variable_1" value="option A|option B|option C"]

WITNESSED SEIZURE AT GROCCERY STORE 
NO BLEED ON CT
NEED EEG AND NEURO CONSULT

NEW ONSET AFIB
FIBROSIS = NEEDS CARDS 
ELOQUIZ = CHAD 2 VASQ