Cardiovascular
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REASON OF CONSULT:
[textarea name="reason_consult_1" default="Paste text reason of consult request"]

ATTENDING CONSULTED: [select name="variable_1" value="Dr. Prabhu|Dr. Asti|Dr. Chawla|Dr. Gopi"]

Admission date: [date name="variable_1" default="03/11/2019"]
HISTORY PRESENT ILLNESS AS PER ADMITTING RESIDENT:
[textarea name="hpi_1" default="Patient is a xx year-old M/F presents to the ED complaining of ________ who is admitted for"]

ALLERGIES: [text name="allergies_1" default="NKDA"]
PAST MEDICAL HISTORY: [textarea name="pmhx_1" default="no significant"]
PAST SURGICAL HISTORY: [textarea name="pshx_1" default="no significant"]
PAST SOCIAL HISTORY: [textarea name="psshx" default="no smoke, no alcohol, no drugs"]
PAST FAMILY HISTORY: [textarea name="pfhx_1" default="no significant"]

HOME MEDICATIONS:
[textarea name="homemeds_1" default="sample text"]

REVIEW OF SYSTEMS:
[checkbox name="ros_1" value="Constitutional: No fevers, changes in weight, fatigue, night sweats
|Head: No headache, sinus congestion or pain
|Ears: No ear pain, discharge, hearing loss, tinnitus, vertigo
|Eyes No changes in vision, eye pain, diplopia, photophobia
|Nose: No nasal discharge, coryza, sneezing, epistaxis
|Throat: No cough, sore throat, dysphagia, odynophagia
|Skin: No diagnosed skin conditions, new lesions, rashes, discoloration, dryness, hair changes
|Heme: No easy bruising, easy bleeding
|CV: No chest pain, palpitations, edema, presyncope, decrease in exercise tolerance
|Resp: No expectoration, dyspnea with rest or exertion, increased puffer use, orthopnea, PND, wheeze
|GI: No abdominal pain, nausea, vomiting, diarrhea, constipation, melena, appetite changes, dyspepsia, belching
|GU: No dysuria, frequency, urgency, hematuria, nocturia, incontinence, dribbling, hesitancy, retention, flank pain|Male: Denies discharge, lesions, testicular pain, hernias
|Female: Denies discharge, lesions, changes in dysmenorrhea, PMS, menstrual frequency, duration, flow, or symptoms
|MSK: No new weakness, arthralgias, myalgias
|Neuro: No weakness, confusion, numbness, dizziness, imbalance|Endocrine: No polydipsia, polyuria, heat/cold sensitivity
|Pain: No new or unexplained pain
|Psychology: No new or worsening depression, anxiety, or insomnia, stress, anger
|Social: No change in home, relationships, employment, substance use, exercise, exposure
|Function: No change in ADLs or IADLS, memory, capacity"]

VITAL SIGNS:

PHYSICAL EXAM:
[select memo="<--- Select Exam" name="exam" value="General Adult Exam|General Male Exam|General Female Exam"]
[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=1 default="HEAD: normocephalic."]
[textarea cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]
[textarea cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]
[textarea cols=80 rows=1 default="NOSE: No nasal discharge."]
[textarea cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]
[textarea cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea cols=80 rows=2 default="LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea cols=80 rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=2 default="BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm."]
[textarea cols=80 rows=2 default="EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[textarea cols=80 rows=5 default="LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
[textarea cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."][conditional field="exam" condition="(exam).is('General Male Exam')"][textarea cols=80 rows=2 default="RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular."][/conditional]
[conditional field="exam" condition="(exam).is('General Male Exam')"][textarea cols=80 rows=3 default="GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge."][/conditional][conditional field="exam" condition="(exam).is('General Female Exam')"][textarea cols=80 rows=1 default="BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."][/conditional]
[conditional field="exam" condition="(exam).is('General Female Exam')"][textarea cols=80 rows=3 default="PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness."][/conditional]
LABORATORY:
MICROBIOLOGY:
IMAGING:
[textarea name="imaging_1" default="TYPE IMAGING REPORTS"]
CURRENT MEDICATION:

SUMMARY:
The patient is a [text default="AGE"] year-old [select name="variable_sex" value="male|female"] who presented to the [text default="ED"] complaining of [text default="CHIEF COMPLAINT"] that began [text default="ONSET"] while [text default="CONTEXT"]. Symptoms have been [text default="TIMING"] since onset and [select name="variable_sex1" value="he|she"] rates them as [text default="SEVERITY"] in severity. Patient reports the symptoms are located [text default="LOCATION"] and describes the quality as [text default="QUALITY"]. Per patient, [select name="variable_sex1" value="he|she"] has had associated [text default="POSITIVE SYMPTOMS"] but denies any [text default="NEGATIVE SYMPTOMS"]. Symptoms are improved with [text default="MODIFYING FACTOR"] and exacerbated by [text default="MODIFYING FACTOR"]. Patient [select name="variable_reports" value="reports|denies"] history of similar symptoms. Pertinent medical history includes [text default="PERTINENT PAST MEDICAL HISTORY"]. Patient adds [text default="OTHER DETAILS"].

*** CAD Risk Factors:
[select value="no|YES"] <-- Diabetes mellitus
[select value="no|YES"] <-- Hypertension
[select value="no|YES"] <-- Tobacco use.
[select value="no|YES"] <-- Hyperlipidemia
[select value="no|YES"] <-- Peripheral Artery Disease (PAD)
[select value="no|YES"] <-- Obesity
[select value="no|YES"] <-- Inactivity
[select value="no|YES"] <-- Family history (female<65, male<55)

*** Pertinent Medications:
[select value="no|YES"] <-- Aspirin
[select value="no|YES"] <-- Clopidogrel
[select value="no|YES"] <-- Anticoagulation

*** HTN is [select name="variable_1" value="appropriately controlled|poorly controlled."]
-Current 10 year ASCVD risk: [text name="variable_1" default=""]. Per USPSTF guidelines, [select name="variable_2" value="recommend high intensity statin therapy, 80 mg Lipitor once daily.|recommend moderate intensity statin therapy, 40 mg Lipitor once daily.|recommend low-intensity statin therapy.|no indication for statin therapy at this time"]
- Goal blood pressure is 140/90
- Medications:

ASSESSMENT:
[textarea name="assessment_1" default="xx-year-old M/F"]

RECOMMENDATIONS:
1)
2)
3)
4)
5)

D/w primary team.

Patient seen, examined, and discussed with Pulmonary attending Dr.
[checkbox name="note_draft_1" value="** NOTE IS STILL IN DRAFT WILL UPDATE AFTER ROUNDS **"] [comment memo="Check if you want this text show up in output"]
REASON OF CONSULT:


ATTENDING CONSULTED:

Admission date:
HISTORY PRESENT ILLNESS AS PER ADMITTING RESIDENT:


ALLERGIES:
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
PAST SOCIAL HISTORY:
PAST FAMILY HISTORY:

HOME MEDICATIONS:


REVIEW OF SYSTEMS:


VITAL SIGNS:

PHYSICAL EXAM:
<--- Select Exam



















LABORATORY:
MICROBIOLOGY:
IMAGING:

CURRENT MEDICATION:

SUMMARY:
The patient is a year-old who presented to the complaining of that began while . Symptoms have been since onset and rates them as in severity. Patient reports the symptoms are located and describes the quality as . Per patient, has had associated but denies any . Symptoms are improved with and exacerbated by . Patient history of similar symptoms. Pertinent medical history includes . Patient adds .

*** CAD Risk Factors:
<-- Diabetes mellitus
<-- Hypertension
<-- Tobacco use.
<-- Hyperlipidemia
<-- Peripheral Artery Disease (PAD)
<-- Obesity
<-- Inactivity
<-- Family history (female<65, male<55)

*** Pertinent Medications:
<-- Aspirin
<-- Clopidogrel
<-- Anticoagulation

*** HTN is
-Current 10 year ASCVD risk: . Per USPSTF guidelines,
- Goal blood pressure is 140/90
- Medications:

ASSESSMENT:


RECOMMENDATIONS:
1)
2)
3)
4)
5)

D/w primary team.

Patient seen, examined, and discussed with Pulmonary attending Dr.
Check if you want this text show up in output
Result - Copy and paste this output: