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[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="acutely ill|chronically ill|frail|robust|vigorous|well-nourished|cachexic"]
Patient is [checkbox name="variable_1" value="alert|awake|asleep|responds to verbal stimuli|responds to pain|unresponsive|lethargic|unconscious|sedated"]
[checkbox name="variable_17" value="no signs of distress|clutching the chest|pallor|diaphoretic|labored breathing|wincing|sweating|fidgety|anxious|poor eye contact|no acute distress"]
HEENT
Head: [checkbox name="variable_19" value="normocephalic|atraumatic|no masses or lesions"][text name="variable_20" default=""]
Eyes: [checkbox name="variable_21"="variable_1" value="PERRLA|EOMI|anticteric|injection|no injection|papilledema|no papilledema| no vision changes|glasses present|white|red eye|conjunctivitis|jaundice|episclerritis"][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|bruit|no bruit"][text name="variable_33" default=""]
LUNGS: [checkbox name="variable_35" value="symmetric expansion|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|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 bruits on the left|carotid bruits on the right|bilateral carotid bruit|JVD|no JVD"][text name="variable_38" default=""]
ABDOMEN[checkbox name="variable_39" value="obese|flat|rounded|soft|firm|rigid|non-distended|distended|non-tender|tympany 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 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="alert and oriented x 3|CN II - XII intact|strength and sensation symmetric and intact throughout.|The patient was able to demonstrate good judgement and reason, without hallucinations.|alert|responds to voice|responds to pain|unresponsive|confused|obtunded|awake|quiet|crying|drowsy|easily aroused|easily consoled"] [checkbox value="oriented to place|oriented to time|oriented to situation|oriented to person|disoriented"]
[comment memo="Neuro complete"]
NEUROLOGICAL:
Gait: [select name="G1" value="steady coordinated gait|abnormal"][conditional field="G1" condition="(G1).is('abnormal')"][checkbox value="an unsteady uncoordinated gait|a slow unsteady gait|walks on heels and toes with out problems|has difficulty with walking"][/conditional] [text]
Rhomberg: [select value="negative|postive"] [text]
Rapid alternating movements: [select value="normal|abnormal"] [text]
Cranial nerves: [select value="II-XII intact|abnormal"] [text]
cranial nerves II-XII intact.
Sensation: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Strength: [select value="intact and symmetric at upper and lower extremities bilaterally|abnormal"] [text]
Reflexes:
[checkbox memo="Right Biceps" name="RB" value=""][conditional field="RB" condition="(RB).is('')"]Right Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Biceps" name="LB" value=""][conditional field="LB" condition="(LB).is('')"]Left Biceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Triceps" name="RT" value=""][conditional field="RT" condition="(RT).is('')"]Right Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Triceps" name="LT" value=""][conditional field="LT" condition="(LT).is('')"]Left Triceps: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Forearm" name="RF" value=""][conditional field="RF" condition="(RF).is('')"]Right Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Forearm" name="LF" value=""][conditional field="LF" condition="(LF).is('')"]Left Forearm: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Patella" name="RP" value=""][conditional field="RP" condition="(RP).is('')"]Right Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Patella" name="LP" value=""][conditional field="LP" condition="(LP).is('')"]Left Patella: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Right Ankle" name="RA" value=""][conditional field="RA" condition="(RA).is('')"]Right Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional][checkbox memo="Left Ankle" name="LA" value=""][conditional field="LA" condition="(LA).is('')"]Left Ankle: [select value="2+ (normal). |0 (absent). |1+ (hypoactive). |2+ (normal). |3+ (hyperactive without clonus). |4+ (hyperactive with clonus). "][/conditional]
Babinski: [select value="negative|postive"] [text]
The following other neurologic findings were found: [textarea default="none"]
PSYCH:
[checkbox value="appropriate judgment|appropriate safety awareness|appropriate attention/concentration|follows commands|impulsive|poor judgment|poor safety awareness|poor attention|concentration|restless|unable to follow commands|uncooperative"][text name="variable_45" default=""]




REVIEW OF MEDICATIONS

[textarea name="variable_47" default=""]
DIAGNOSTICS
[textarea name="variable_48" default=""]
[comment memo="repeat one liner"]<br>
[textarea name="variable_4" default=""]<br>
A/P[comment memo="remember complicated vs uncomplicated, acute vs chronic, provoked vs unprovoked"]
[comment memo="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=""]

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:
GENERALApparent state of health

Patient is

HEENT
Head:
Eyes:
Ears:
Nose:
Mouth/Throat:
Lips:
NECK:

LUNGS:
CARDIOVASCULAR:
ABDOMEN
EXTREMITIES

SKIN
NEURO

Neuro complete
NEUROLOGICAL:
Gait:
Rhomberg:
Rapid alternating movements:
Cranial nerves:
cranial nerves II-XII intact.
Sensation:
Strength:
Reflexes:
Right Biceps Left Biceps Right Triceps Left Triceps Right Forearm Left Forearm Right Patella Left Patella Right Ankle Left Ankle
Babinski:
The following other neurologic findings were found:
PSYCH:





REVIEW OF MEDICATIONS


DIAGNOSTICS

repeat one liner<br>
<br>
A/Premember complicated vs uncomplicated, acute vs chronic, provoked vs unprovoked
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: