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[comment memo="Today's date"][date name="variable_5" default=""]
Admit date: [date name="variable_177" default=""]
[comment memo="one-liner"]
[textarea name="variable_4" default=""]
S:
[textarea name="variable_6" default=""]
[comment memo="Any overnight events. OLDCARTS all symptoms. Include pertinent negatives and positives based on patient's complaint. Include if patient is feeling better/worse/same than when admitted or day before; Also, include any new complaints"]
O:
Temperature: [text name="variable_7" default=""]
Pulse: [text name="variable_8" default=""] Rhythm: [text name="variable_9" default=""]
RR: [text name="variable_10" default=""]
BP: [text name="variable_11" default=""]
Pox: [text name="variable_12" default=""] on [text name="variable_59" default=""]
Weight: [text name="variable_13" default=""]
Pain: [text name="variable_717" default=""]
I/O: [text name="variable_14" default=""]
Lines: [text name="variable_15" default=""]

PHYSICAL EXAM:
GENERAL:[comment memo="Apparent state of health"]
[checkbox name="variable_1"="variable_16" value="Lying in bed in no acute distress.|Acutely ill|Chronically ill|Frail|Robust|Vigorous|Well-nourished|Cachexic|Calm demeanor|Appropriate to situation|Well-groomed|Well-developed|Appears stated age"]
[checkbox name="variable_17" value="No signs of distress.|Clutching the chest.|Pallor|Diaphoretic|with labored breathing.|Wincing.|Sweating.|Anxious.|Poor eye contact.|No acute distress."]
HEENT
HEAD: [checkbox name="variable_19" value="Normocephalic and atraumatic, No masses or lesions present.|Normocephalic.|Atraumatic.|No masses or lesions."][text name="variable_20" default=""]
EYES: [checkbox name="variable_21"="variable_1" value="Pupils PERRLA, EOMI intact.|PERRLA.|EOMI.|Anticteric|Icteric|Injection|No injection|Papilledema|No papilledema| No vision changes.|Glasses present.|Conjunctivitis.|Jaundice|Episcleritis.|No nystagmus.|Nystagmus present."][text name="variable_24" default=""]
EARS: [checkbox name="variable_25"="variable_1" value="Discharge|No discharge|Hearing intact.|Hard of hearing|Deaf|Hearing aide(s) present."][text name="variable_26" default=""]
NOSE: [checkbox name="variable_27"="variable_1" value="Red|Symmetric.|Asymmetric|Rhinorhea.|Discharge|No discharge"][text name="variable_28" default=""]
MOUTH/THROAT: [checkbox name="variable_29" value="Oral cavity and pharynx normal.|Dry|Moist|Mucous membranes intact.|Dental caries present.|Edentulous.|Tongue symmetric.|Positive gag reflex.|No gag reflex."][text name="variable_30" default=""]
LIPS: [checkbox name="variable_62" value="Dry|Cracked|Intact"][text name="variable_31" default=""]
NECK:[checkbox name="variable_32" value="Supple and midline.|Neck rigid|Visible goiter.|No visible goiter.|Edema|Discoloration|Lymph palpable.|Carotid bruits bilaterally.|Right carotid bruit present.|Left carotid bruit present.|No carotid bruits present bilaterally."][text name="variable_33" default=""]
LUNGS: [checkbox name="variable_35" value="Respirations are symmetric and unlabored. Clear breath sounds auscultated in all fields without rales, rhonchi, or wheezing noted.|Accessory muscle use.|No accessory muscle use.|Clear to auscultation through all fields.|without rales, wheezes, or rhonchi|Diminished breath sounds.|without rales|with rales|without rhonchi|with rhonchi|Audible wheeze|without wheezing|Inspiratory wheeze|Expiratory wheeze|Stridor|Tachypnea|Barrel chest|Tactile fremitus present.|No tactile fremitus.|Dull to percussion.|Hyper-resonance to percussion.|Tympanic to percussion.|Resonant to percussion.|Bronchophony present.|Egophony present.|Whispered pectoriloquy present."][text name="variable_36" default=""]
CARDIOVASCULAR: [checkbox name="variable_37" value="S1S2. No S3 or S4 present. No murmurs, gallops,or rubs.|S1S2.|no S3 or S4.|No murmurs,gallops,or rubs|S3 present.|S4 present|Murmur present.|Holosystolic murmur.| mid systolic murmur|late systolic murmur|diastolic murmur|loudness 1/6|loudness 2/6| loudness 3/6| loudness 4/6| loudness 5/6| loudness 6/6| Rhythm is regular.|Rhythm is irregular.|Rhythm is irregularly irregular.|Peripheral pulses are 2+ throughout.|Peripheral pulses are diminished.|Peripheral pulses are absent.|No carotid bruits.|Carotid bruit on the left.|Carotid bruit on the right.|Bilateral carotid bruits.|JVD.|No JVD."][text name="variable_38" default=""]
ABDOMEN:[checkbox name="variable_39" value="Abdomen is soft, non-tender, and non-distended. Bowel sounds present in all quadrants.|Obese|Flat|Rounded|Soft|Firm|Rigid|Non-distended|Distended|Non-tender|Tymphany to percussion|Hepatomegaly.|Splenomegaly.|Scar noted.|Bowel sounds present in all four quadrants.|Bowel sounds are hypoactive in all quadrants.|Bowel sounds are absent in all quadrants.|Bowel sounds hyperactive in all four quadrants.|No bruits.|Abdominal bruit.|Right femoral artery bruit.|Left femoral artery bruit.|Bilateral femoral bruits.|No guarding.|Guarding.|No rebound tenderness.|Rebound tenderness present.|No abdominal tenderness to palpitation.|Suprapubic tenderness.|Diffuse tenderness.|RLQ tenderness.|LLQ tenderness.|RUQ tenderness.|LUQ tenderness.|Hernia present.|No masses.|Mass present."][text name="variable_40" default=""]
EXTREMITIES:[checkbox name="variable_41" value="MAE. Active ROM.|No lymphedema.|No swelling.|Swelling present.|+2 peripheral pulses all extremities.|Decreased peripheral pulses.|Absent peripheral pulses.|No dependent edema.|No tenderness in calves.|No skin changes in extremities.|Stasis dermatitis.|Wound(s) present."][text name="variable_42" default=""]
SKIN:[checkbox name="variable_43" value="No growths, rashes, or hair loss.|Dry skin present.|Jaundice present.|Skin warm and dry.|Skin warm and moist.|Skin cool and pale.|Skin cool and dry.|Scattered ecchymosis present.|Wound present."][text name="variable_44" default=""]
NEURO:[checkbox value="AAOx3. CN III-XII intact. EOMI.|Alert and oriented x 3|CN III - XII intact|Strength and sensation symmetric and intact throughout.|Alert|Responds to voice|Responds to pain|Unresponsive|Confused|Obtunded|Awake|Stupor|Comatose"] [checkbox value="Oriented to place|Oriented to time|Oriented to situation|Oriented to person|Disoriented"]
PSYCH: [checkbox value="The patient was able to demonstrate good judgement and reason, without hallucinations.|Appropriate judgment.|Appropriate safety awareness.|Appropriate attention/concentration.|Impulsive.|Poor judgment.|Poor safety awareness.|Poor attention/Concentration|Restless.|Unable to follow commands.|Uncooperative.|Delirious."][text name="variable_45" default=""]

REVIEW OF MEDICATIONS

[textarea name="variable_47" default=""]
DIAGNOSTICS
[textarea name="variable_48" default=""]
[comment memo="repeat one liner"]
[textarea name="variable_4" default=""]
A/P
[comment memo="remember complicated vs uncomplicated, acute vs chronic, provoked vs unprovoked"]
[comment memo="Address What? Why? What's next?"]
# [textarea name="variable_49" default=""]
# [textarea name="variable_50" default=""]
# [textarea name="variable_51" default=""]
# [textarea name="variable_52" default=""]
# CHRONIC
[textarea name="variable_53" default=""]
# GLOBAL
Diet:[text name="variable_54" default=""]
VTE:[text name="variable_55" default=""]
Code: [text name="variable_56" default=""]
Dispo: [text name="variable_57" default=""]

[comment memo="Reflection to CAF"]
[comment memo="1. Was this case particularly challenging for you? if yes, why?"]
[textarea name="variable_66" default=""]
[comment memo="2. What is a clinical pearl that you learned from the case?"]
[textarea name="variable_67" default=""]
[comment memo="3. Provide a clinical relevant reference out of your course reading to support the clinical decisions made in this case"]
[textarea name="variable_68" default=""]
[comment memo="4. If you disagreed with the treatment of the case, discuss why and provide evidence to back up your position"]
[textarea name="variable_69" default=""]
Today's date
Admit date:
one-liner

S:

Any overnight events. OLDCARTS all symptoms. Include pertinent negatives and positives based on patient's complaint. Include if patient is feeling better/worse/same than when admitted or day before; Also, include any new complaints
O:
Temperature:
Pulse: Rhythm:
RR:
BP:
Pox: on
Weight:
Pain:
I/O:
Lines:

PHYSICAL EXAM:
GENERAL:Apparent state of health


HEENT
HEAD:
EYES:
EARS:
NOSE:
MOUTH/THROAT:
LIPS:
NECK:
LUNGS:
CARDIOVASCULAR:
ABDOMEN:
EXTREMITIES:
SKIN:
NEURO:
PSYCH:

REVIEW OF MEDICATIONS


DIAGNOSTICS

repeat one liner

A/P
remember complicated vs uncomplicated, acute vs chronic, provoked vs unprovoked
Address What? Why? What's next?
#
#
#
#
# CHRONIC

# GLOBAL
Diet:
VTE:
Code:
Dispo:

Reflection to CAF
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 out 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

Result - Copy and paste this output: