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History & Physical
Date:[date name="date" default=""]
Demographics (or one-liner):
[textarea="demographics" default=""]
[comment memo="Name, age, race, gender, employment, residence (these are Drexel specific requirements)"]
Source:
[text name="Source" default=""]
[comment memo="Source of Hx and reliability"]
[checkbox name="Reviewed old records." value="Reviewed old records."]
Chief Complaint:[textarea name="CC" default=""]
[comment memo="symptom and duration - in patient's own words"]
HPI:[textarea name="hpi" default=" "]
[comment memo="Start with open-ended questions and then tighten up the story as you go along. A usual sentence to start can be: Patient was in their usual state of health until x days prior to admission...presented with..."]
[comment memo="Include the following information, written in prose, not a list or sentence fragments, not under separate headings.
Chronological story of chief complaint, including:
- details of symptoms - use OLDCART or PQRST
- Pertinent (+) from PMH, lack of risk factors, FH, SH, ROS
- Ask appropriate ROS questions for the organ systems involved in the chief complaint at the end of HPI
- Pertinent (-) from PMH, lack of risk factors, FH, SH, ROS ie. lack of smoking in pt. with hemoptysis"]
ALLERGIES:[checkbox name="NKDA" value="NKDA"]
[text name="allergy" default="allergies here"]
Home Medications:
[textarea name="meds" default=""]
[comment memo="include OTC, herbal, vitamins. Dosage if known. Generic (Trade) names."]
PMHx:
[textarea name="PMH" default=""]
[comment memo="list under each relevant heading below. Include year if known."]
Birth history/Childhood illnesses[text name="Birth history/Childhood illnesses:" default=""]
Surgeries/Procedures/Traumas: [text name="surgeries" default=" "]
Obstetrical:
[text name="variable_1" default=""]
[comment memo="GxPx, TPAL (term, pre-term, aborted, live), SVD (spontaneous vaginal delivery)"]
Hospitalizations: [text name="hospitalizations" default=""]
Psychiatric:
[text name="psychiatric" default=""]
IMMUNIZATIONS:
[checkbox name="Up to date" value="Up to Date."]
[text name="immunizations" default=""]
FHx: [textarea name="fhx" default="Paternal grandmother:, Paternal grandfather:, Maternal grandmother: ,Maternal grandfather:, Siblings: , Kids: "]
SocialHx: [textarea name="shx" default=" "]
[comment memo="employment, living situation,educational background, religion, habits, Don't forget recent travel if pertinent to the CC"]
Drugs:
[text name="drugs" default=""]
Alcohol:
[text name="alcohol" default=""]
Tobacco:
[text name="tobacco" default=""]

ROS:

-Constitutional: [checkbox name="ros_constitutional_check" value="no fever|no chills|no night sweats|no fatigue|no changes in weight"][text name="ros_constitutional" default=" "]
-Skin: [checkbox name="ros_skin_check" value="no rash|no bruising|no lesions|color and/or pigmentation changes|ecchymosis|pruritis|rash|dryness|urticaria|pressure ulcer|abscess|sunburn|changes in mole|new lesion"][text name="ros_skin" default=" "]
- Hair:
[checkbox name="hair" value="changes in color|texture|distribution|hair loss"]
[text name="hair_ros" default=""]
-HEENT:
Head: [checkbox name="Head" value="headaches|trauma|jaw pain"]
[text name="blank" default=""]
[textarea name="head_ros" default=""]
Eyes:
[checkbox name="eyes" value="date of last exam|visual acuity| color blindness|corrective lenses|photophobia|diplopia|blurred vision| scotomata| glaucoma|cataracts|infection|inflammation|pain|pruritis|trauma|surgery"]
[text name="eyes_ros" default=""]
Ear:
[checkbox name="ear" value="auditory acuity|tinnitus|infection|discharge|pain|mastoiditis|surgery|medications"]
[textarea name="ear_ros" default=""]
Nose:
[checkbox name="nose" value="epistaxis|obstruction|anosmia|rhinorrhea|rhinitis|sinusitis|pain|surgery"]
[textarea name="nose_ros" default=""]
Mouth & Throat:
[checkbox name="mouth" value="dental hx|last exam|gingival bleeding|ulcers|pain|lumps|illusionists|pharyngitis|voice changes|surgery|difficulty swallowing|changes in oral mucosa or tongue"]
[textarea name="mouth_ros" default=""]
Neck:
[checkbox name="neck" value="stiffness|pain|tumors|lymphadenitis|thyroid disorder|injury"]
[textarea name="neck_ros" default=""]
Breast & Axilla:
[checkbox name="breast" value="lumps|tenderness|trauma|nipple discharge|self breast exam|mammogram"]
[textarea name="breast_ros" default=""]
-Respiratory:[checkbox name="ros_resp_check" value="cough|sputum|dyspnea|pleurisy|dyspnea|cyanosis|TB or exposure|pneumonia|bronchitis|asthma|COPD|night sweats"]
[text name="ros_resp" default=" "]
-Cardiovascular: [checkbox name="ros_cardio_check" value="chest pain|angina|palpitations|irregular rhythm|tachycardia|bradycardia|hypertension|hypotension|murmur|heart failure|DOE|orthopnea|PND|rheumatic fever|peripheral edema"][text name="ros_cardio" default=" "]
- PV:
[checkbox name="PV" value="intermittent claudication|varicosities|phlebitis|Raynaud's phenomenon"]
-GI: [checkbox name="ros_gi_check" value="change in appetite|thirst|nausea/vomiting|dysphagia|eructations|flatulence|pyrosis(heartburn)|GERD|hematemesis|cramping|abdominal pain|hernia present|melena|hematochezia|acholic|hemorrhoids|jaundice"][text name="ros_gi" default=" "]
-GU: [checkbox name="ros_gu_check" value="frequency|oliguria/polyuria|nocturia|enuresis|dysuria|hesitancy|decreased stream|dribbling|retention|urgency|incontinence|hematuria|pyuria|urethritis|discharge|UTI or STI|calculus|back or flank pain| surgery"]
[text name="ros_gu" default=" "]
- Male GU:
[checkbox name="male_gu" value="prostatitis|prostatic hyperplasia|penile pain|erectile dysfunction|scrotal pain|testicular pain"]
[text name="malegu" default=""]
Female GU:
[checkbox name="femaleGU" value="age at menarche|LMP|menstrual regularity|frequency|dysmenorrhea|amenorrhea|menorrhagia|spotting|metrorrhagia|PMS|dysparenunia|vaginal discharge|menopause"]
[text name="gufemale" default=""]
-Musculoskeletal: [checkbox name="ros_msk_check" value="pain in muscles|bone pain|joint pain|decreased ROM|joint stiffness|joint edema|gout|deformities|arthritis|fractures|dislocations|myositis|muscular weakness|atrophy"][text name="ros_msk" default=" "]
-Neuro: [checkbox name="ros_neuro_check" value="paresis|paralysis|paresthesia|hyperesthesia|hypesthesia|seizures|dizziness|syncope|coma| disturbance of taste|visual disturbances|aphasia|memory loss| problems with cognition|ataxia|incoordination|tremor|tics"][text name="ros_neuro" default=" "]
-Psych: [checkbox name="ros_psych_check" value="childhood behavioral problems|anxiety|irritability|mood disorders|suicidality|personality disorders|sleep changes| insomnia| alcoholism|drug abuse history"][text name="ros_psych" default=" "]
-Hematologic: [checkbox name="ros_heme_check" value="anemia|bruising|bleeding tendencies| transfustions|hemoglobinopathies|hymphangitis|lymphadenopathy"][text name="ros_heme" default=" "]
-Endocrine: [checkbox name="ros_endo_check" value="heat/cold intolerance|weight changes|anorexia|polyphagia|polydipsia|polyuria|glycosuria|diaphoresis"][text name="ros_endo" default=" "]

PHYSICAL EXAM:

-Vitals:BP: [text name="BP" default=" "]
HR: [text name="HR" default=""]
RR: [text name="Resp rate" default=""]
Temp [text name="temp" default=""]
Pulse ox:
[text name="PO" default=""]
Height:
[text name="height" default=""]
Weight:
[text name="wt" default=""]
BMI:
[text name="BMI" default=""]
Pain:
[text name="pain" default=""]

-General: [checkbox name="pe_general_check" value="well-developed|well-developed|in no acute distress|overweight|obese|cachexic|appears comfortable"][text name="pe_general" default=" "]
-Head:
[checkbox name="head" value="atraumatic|noncephalic"]
-HEENT: [checkbox name="pe_heent_check" value="PERRLA|white sclera|conjuntica pink|ears patent|TM intact|Wax present|erythematous pharynx| normal pharynx|TM bulging|TM retracted|TM Perf|Serous fluid present"][text name="pe_heent" default=" "]
- Neck:
[text name="neck" default="supple, no JVD, and midline"]
[text name="neck_PE" default=""]
-Cardiovascular: [checkbox name="pe_cardio_check" value="normal S1 S2|No S3 or S4|No murmurs, rubs, gallops|no carotid bruits|no edema|peripheral pulses intact|no cyanosis|capillary refill < 2 seconds|chest pain|no edema][text name="pe_cardio" default=" "]
-Respiratory: [checkbox name="pe_resp_check" value="CTA bilaterally|no rales, rhonchi,or wheezes|no retractions|no use of accessory muscles|use of accessory muscle"][text name="pe_resp" default=" "]
-GI:[checkbox name="pe_gi_check" value="BS present in all 4 quadrants|abdomen soft/nontender to palpation|nondistended|No rigidity|no guarding|no masses|appetite: |thirst| nausea|vomiting|dysphagia|eructations|flatulence|heartburn|GERD|Barret's| hematemesis|cramping|abdominal pain|hernia|stool color: | stool frequency: | melena|hematochezia|hemorrhoids|jaundice"][text name="pe_gi" default=" "]
-GU: [checkbox name="pe_gu_check" value="No CVA tenderness|no suprapubic pain|frequency|oliguria|polyuria|nocturia|enuresis|dysuria|hesitancy|decreased stream|dribbling|retention|urgency|incontinence|hematuria|pyuria|urtheritis|discharge|UTI|STI|back or flank pain "][text name="pe_gu" default=" "]
-MSK: [checkbox name="pe_msk_check" value="normal ROM|no pain on palpation|strength 5/5 in all extremities"][text name="pe_msk" default=" "]
-Skin: [checkbox name="pe_skin_check" value="no rash|no lesion|no discoloration"][text name="pe_skin" default=" "]
-Neuro: [checkbox name="pe_neuro_check" value="Grossly oriented X 4|gait WNL|sensation intact|normal reflexes"][text name="pe_neuro" default=" "]
-Psych: [checkbox name="pe_psych_check" value="Pleasant, calm and cooperative|Judgement and insight intact|thought process normal|normal affect"][text name="pe_psych" default=" "]
-Hematologic: [checkbox name="pe_heme_check" value="cervical lymphadenopathy|no lymphadenopathy|no tenderness or masses palpated|no bruises"][text name="pe_heme" default=" "]

LAB & IMAGING RESULTS
[textarea name="labs" default=""]


ASSESSMENT/PLAN:
[textarea name="anp" default="1."]
[comment memo="List ALL suspected/current diagnoses in medical language, explaining all items in problem list. For EACH impression, indicate what was done, what orders are pending, what will be done in the future and follow-up. Don't forget pt education and F/U "]

[comment memo="Below is for clinical note to CAF @ Drexel"]
DISCUSSION
[textarea name="variab" default=""]

[comment memo="Use medical language to present a chronological explanation for pt's CC and resulting symptoms (patho). Discuss prognosis if relevant or next step to undertake (plan). Also, consider things to be concerned about in future."]

1. Was this case particularly challenging for you? If yes why?
[textarea name="q_1" default=""]

2. What is a clinical PEARL that you learned from the case?
[textarea name="v" default=""]

3. Provide a clinical relevant reference outside of your course reading to support the clinical decisions made in this case
[textarea name="va" default=""]

4. If you disagreed with the treatment of the case – discuss why and provide evidence to back up your position
[textarea name="vari" default=""]

All associated references need to be in APA format.
History & Physical
Date:
Demographics (or one-liner):

Name, age, race, gender, employment, residence (these are Drexel specific requirements)
Source:

Source of Hx and reliability

Chief Complaint:
symptom and duration - in patient's own words
HPI:
Start with open-ended questions and then tighten up the story as you go along. A usual sentence to start can be: Patient was in their usual state of health until x days prior to admission...presented with...
Include the following information, written in prose, not a list or sentence fragments, not under separate headings.
Chronological story of chief complaint, including:
- details of symptoms - use OLDCART or PQRST
- Pertinent (+) from PMH, lack of risk factors, FH, SH, ROS
- Ask appropriate ROS questions for the organ systems involved in the chief complaint at the end of HPI
- Pertinent (-) from PMH, lack of risk factors, FH, SH, ROS ie. lack of smoking in pt. with hemoptysis

ALLERGIES:

Home Medications:

include OTC, herbal, vitamins. Dosage if known. Generic (Trade) names.
PMHx:

list under each relevant heading below. Include year if known.
Birth history/Childhood illnesses
Surgeries/Procedures/Traumas:
Obstetrical:

GxPx, TPAL (term, pre-term, aborted, live), SVD (spontaneous vaginal delivery)
Hospitalizations:
Psychiatric:

IMMUNIZATIONS:


FHx:
SocialHx:
employment, living situation,educational background, religion, habits, Don't forget recent travel if pertinent to the CC
Drugs:

Alcohol:

Tobacco:


ROS:

-Constitutional:
-Skin:
- Hair:


-HEENT:
Head:


Eyes:


Ear:


Nose:


Mouth & Throat:


Neck:


Breast & Axilla:


-Respiratory:

-Cardiovascular:
- PV:

-GI:
-GU:

- Male GU:


Female GU:


-Musculoskeletal:
-Neuro:
-Psych:
-Hematologic:
-Endocrine:

PHYSICAL EXAM:

-Vitals:BP:
HR:
RR:
Temp
Pulse ox:

Height:

Weight:

BMI:

Pain:


-General:
-Head:

-HEENT:
- Neck:


-Cardiovascular:
-Respiratory:
-GI:
-GU:
-MSK:
-Skin:
-Neuro:
-Psych:
-Hematologic:

LAB & IMAGING RESULTS



ASSESSMENT/PLAN:

List ALL suspected/current diagnoses in medical language, explaining all items in problem list. For EACH impression, indicate what was done, what orders are pending, what will be done in the future and follow-up. Don't forget pt education and F/U

Below is for clinical note to CAF @ Drexel
DISCUSSION


Use medical language to present a chronological explanation for pt's CC and resulting symptoms (patho). Discuss prognosis if relevant or next step to undertake (plan). Also, consider things to be concerned about in future.

1. Was this case particularly challenging for you? If yes why?


2. What is a clinical PEARL that you learned from the case?


3. Provide a clinical relevant reference outside of your course reading to support the clinical decisions made in this case


4. If you disagreed with the treatment of the case – discuss why and provide evidence to back up your position


All associated references need to be in APA format.

Result - Copy and paste this output:

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