Palliative Admission FINAL

MRN:[text name="MRN" default="0000"]

Patient ID: [text name="variable_1" default=""]

Diagnosis: [textarea name="diagnosis" default=""]

GOC: [select name="GOC" value="C1|C2|S1|S|F"]

PPS:[select name="PPS" value="10%|20%|30%|40%|50%|60%|70%|80%|90%"]

Past    Medical    History
[checkbox name="pmhx" value="HTN|COPD|BPH|IHD|OA|DMII"]
[textarea name="pmhx" default=""]

Current    Medications:    please    see    MedRec    for    complete    details.

Allergies:    [text name="allergies" default="NKDA"]

Social    History:  [var name="variable_1"]    lives    [checkbox name="lives" value="alone|with  ******"]    in    a    [select name="livingcondition" value="house|apartment|assisted    living|nursing    home"].    [select name="religion" value="They    have    no    religious    or    spiritual    affilication|They    identify    as    ******"]. 
[checkbox name="substances" value="Current    smoker|Lifelong    non-smoker|Remote    ex-smoker|Ex-smoker,    quit    ******"]. [var name="variable_1"]    [checkbox name="ETOH" value="drinks    no    ETOH|drinks    ETOH    ******|and has    a    history    of    heavy    drinking|and    has    no    history    of    heavy    drinking"]. [checkbox name="THC" value="They    do    not    use    any    THC/CBD    products|They    use    CBD    ******|They    use    THC    ******"].   There    is    no    other    reported    substance    use.

Investigations
Chart    reviewed.
Labs:    [date name="date1" default=""]
[textarea name="labs" default=""]
Imaging:    [textarea name="imaging" default=""]

Physical    Examination
General:    [checkbox name="general" value="Appears    well,    in    NAD.    Resps    easy.|Increased    WOB    noted.|Somnolent.|Appears    comfortable    during    assessment.|Appeared    uncomfortable    during    assessment.|No    psychomotor    agitation    or    retardation    observed."]
CVS:    [checkbox name="cvs" value="Auscultated    S1S2,    no    audible    murmur.|Auscultated    S1S2,    murmur    audible    ******.|Peripheral    edema    to    the    lower    extremities    bilaterally    ******|No    pedal    edema.|Normal    capillary    refill."]
Resp:[checkbox name="resp" value="Good    AE    bilaterally    to    the    bases without    adventitious    sounds.|Adequate    AE    bilaterally    to    the    bases    bilaterally    without    adventitious    sounds.|Reduced    AE    ******."]
Abdo:    [checkbox name="abdo" value="Soft,    nontender    without    guarding    or    rigidity.|No    HSM.|Tender    abdomen,    ******.|Area    of    fullness    appreciated    ******.|No    signs    of    peritonitis."]
Neuro:[checkbox name="neuro" value="Pupils    equal,    reactive    to    light    bilaterally, normal    size.|Abnormal    pupils    ******|Myoclonus ******.|No    myoclonus.|CN    II-XII    (VIII    not    formally    tested)    within    normal    limits.|Abnormal    CN    testing.|Strength    testing    within    normal    limits    -    5/5    to    the    upper    and    lower    extremity.|Abnormal    strength    testing    ******.|Cerebellar    testing    within    normal    limits.|Abnormal    cerebellar    testing    ******.|Reflexes    normal   ,    2+    at    the    brachioradialis,    biceps,    patella,    and    achilles.|Abnormal    reflexes,    ******| Babinski    testing    negative.|Babinski    testing    positive.|Sensory    testing    within    normal    limits    to    peripheral    extremities.|Impaired    sensation    noted    to    the    ******.|Gait    not    observed.|Gait    ******."]
Skin/MSK: [checkbox name="skin" value="No    skin    breakdown    or    rash.|Skin    breakdown    ******.|Skin    eruption    ******."]
ENT: [checkbox name="ENT" value="Moist    mucous    membranes.|Tongue    appears    dry."]   

Impression    &    Plan
[textarea name="variable_2" default=""]