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Patient’s rights, confidentiality, limits/exceptions to confidentiality, and use of electronic medical records were reviewed with the patient. Verification of patient identity was established with the patient.

DATE: [text name="variable_1"]
CASE ID #[text name="variable_85"]

----------
SUBJECTIVE
----------
CHIEF COMPLAINT: [text name="variable_2"]

HISTORY OF PRESENT ILLNESS:
Patient is a [text name="variable_3"] [select name="variable_1" value="year old|week old"] [select name="variable_1" value="GENDER|male|female"] presenting to [text name="variable_4"] w/ a chief complaint of [text name="variable_5"]. [textarea name="HPI" default=""] Patient denies any associated [checkbox name="Negatives" value="chest pain|shortness of breath|wheezing|cough|hemoptysis|abdominal pain|nausea|vomiting|diarrhea|bloody stools|fever|chills|dysuria|hematuria|abnormal vaginal bleeding or discharge|penile discharge|low back or flank pain|focal neuro deficits|syncope or near syncope|vertigo|disequilibrium|headache|neck pain|neck stiffness|acute visual changes|sore throat|throat swelling|airway compromise issues|drooling or voice change|sinus pressure|ear pain|hearing loss|lip/tongue swelling|rash|foreign body sensation"]. [textarea name="variable_12"] Patient has no other complaints.


REVIEW OF SYSTEMS:
General:
[checklist name="General" value="fever|fatigue|night sweats|change in appetite|change in weight"]
Skin:
[checklist name="Skin" value="rash|itching|change in hair/nails"]
Head:
[checklist name="Head" value="headache|head injury"]
Eyes:
[checklist name="Eyes" value="change in vision|eye pain|double vision|flashing lights|corrective lenses"]
Ears:
[checklist name="Ears" value="change in hearing|ear pain|discharge|ringing|dizziness"]
Nose/Sinus:
[checklist name="NoseSinus" value="nose bleeds|congestion|frequent colds|sinus infections"]
Allergies:
[checklist name="Allergies" value="hives|swelling of lips/tongue|hay fever|asthma|eczema|sensitivity to drugs, foods, pollens, or dander"]
Mouth/Throat:
[checklist name="MouthThroat" value="bleeding gums|sore throat|sore tongue|pain in mouth|sores in mouth|hoarseness"]
Neck:
[checklist name="Neck" value="lumps|swollen glands|goiter|stiffness"]
Breast:
[checklist name="Breast" value="lumps|pain|nipple discharge"]
Cardio:
[checklist name="Cardio" value="chest pain|palpitations|heart murmur|history of heart medications|rheumatic heart disease|high blood pressure|high cholesterol|change in color of fingers or toes|swelling in hands or feet"]
Pulmonology:
[checklist name="Pulm" value="shortness of breath|cough|production of phlegm|coughing up blood|bronchitis|emphysema|COPD"]
GI:
[checklist name="GI" value="problems swallowing|heartburn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|excessive belching|excessing flatus|food intolerance|rectal bleeding|hemorrhoids|yellowing of skin"]
Urinary:
[checklist name="Urinary" value="difficulty in urination|pain or burning with urination|frequent urination at night|urgent need to urinate|incontinence of urine|dribbling|decreased urine stream|blood in urine|UTI|stones|prostate issues"]
Peripheral Vascular:
[checklist name="PeripheralVascular" value="leg cramps|varicose veins|clots in veins"]
Musculoskeletal:
[checklist name="MSK" value="pain|swelling|stiffness|decreased range of motion|broken bone|serious sprains|arthritis|gout"]
Neurologic
[checklist name="Neuro" value="headaches|migraines|seizures|loss of consciousness/fainting|paralysis|weakness|muscle spasm|tremor|involuntary movement|incoordination|numbness|feeling of pins and needles or tingles"]
Hematologic:
[checklist name="Heme" value="anemia|easy bruising|easy bleeding|past transfusions"]
Endocrine:
[checklist name="Endo" value="abnormal growth|increased thirst|increased urine production|thyroid issues|heat/cold intolerance|excessive sweating|diabetes"]
Psychiatric:
[checklist name="Psych" value="anxiety|muscle tension|depression|thoughts of suicide|self harm|thoughts of hurting others|memory issues|sleep issues|change in mood|pleasure in doing things|ADD/ADHD|past treatment with psychiatrist|other psychiatric diagnosis"]

PMHx:
[textarea name="variable_13"]

Surg Hx:
[textarea name="variable_14"]

Family Hx:
[textarea name="variable_15"]

Medications:
[textarea name="variable_16"]

Allergies: [text name="variable_14"]



---------
OBJECTIVE
---------
VITALS:
- HR: [text name="variable_15"]
- RR: [text name="variable_16"]
- BP: [text name="variable_17"]
- T: [text name="variable_18"]
- HT: [text name="variable_19"]
- WT: [text name="variable_20"]


PE FINDINGS:
General:
[textarea name="variable_21" default="Insert abnormalities or delete this text to remove."] [checkbox name="GeneralPE" value="A&Ox4. |Does not appear to be in any acute distress. |Well-groomed. |Appears stated age."]

Neuro:
[textarea name="variable_22" default="Insert abnormalities or delete this text to remove."] [checkbox name="NeuroPE" value="Normal motor function w/ muscle strength 5/5 b/l on UE and LE. |Sensation is intact b/l. |Memory is grossly intact. |Cerebral function and thought process intact. |No gait abnormalities observed. |Neuro exam not performed."]

Integumentary:
[textarea name="variable_23" default="Insert abnormalities or delete this text to remove."] [checkbox name="SkinPE" value="Skin is warm, dry, and intact.|No lesions.|No cyanosis or clubbing. |Integumentary exam not performed."]

HEENT:
[textarea name="variable_24" default="Insert abnormalities or delete this text to remove."] [checkbox name="HEENTPE" value="Head is normocephalic and atraumatic. |Head is w/o tenderness, visible or palpable masses, and depressions. |Hair is of normal texture and distribution. |EOM intact. |PERRLA. |Hearing is grossly intact. |TM is normal in appearance w/ normal landmarks and cone of light. |Nasal mucosa is pink and moist. |Oral mucosa is pink and moist w/ good dentition. |Pharynx is normal in appearance w/o tonsillar swelling or exudates. |Neck is supple w/o any lymphadenopathy. |Trachea is midline. |Thyroid gland is normal w/o any palpable masses. |Carotid pulse 2+ b/l w/o bruit. |No JVD. |HEENT exam not performed."]

Cardiopulmonary:
[textarea name="variable_25" default="Insert abnormalities or delete this text to remove."] [checkbox name="CardpulmPE" value="Heart rate and rhythm are normal. |Normal S1 and S2. |No murmurs, gallops, rubs, or extra heart sounds appreciated upon auscultation. |Chest wall is symmetric and w/o deformity or signs of trauma. |No signs of respiratory distress. |Lungs CTA b/l w/o rales, ronchi, or wheezes. |Cardio exam not performed. |Pulmonary exam not performed."]

GI:
[textarea name="variable_26" default="Insert abnormalities or delete this text to remove."] [checkbox name="GIPE" value="Abdomen is soft, symmetric, and non-tender w/o distention. |No visible lesions or scars. |Aorta is midline w/o bruit or visible pulsation. |Umbilicus is midline w/o herniation. |Normal BS in all four quadrants. |No masses, hepatomegaly, or splenomegaly are noted. |Abdominal exam not performed."]

GU:
[textarea name="variable_27" default="Insert abnormalities or delete this text to remove."] [checkbox name="GUPE" value=" Normal rectal sphincter tone. |No external masses or lesions. |Stool is normal in appearance. |Guac negative. |External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. |Vagina is pink and moist w/o lesions or abnormal discharge. |Uterus is anteflexed, non-tender, and normal in size. |Ovaries are non-tender w/o palpable masses or enlargement. |Circumcised male. |Uncircumcised male. |Prepuce easily retracts. |No penile discharge or lesions. |No scrotal swelling or discoloration. |Testes descended b/l, smooth, no masses. |Epididymis nontender. |No inguinal or femoral hernias. |No GU exam performed. |No rectal exam performed."]

Peripheral Vascular/MSK:
[textarea name="variable_28" default="Insert abnormalities or delete this text to remove."] [checkbox name="PeriVascPE" value="UE and LE are atraumatic in appearance w/o tenderness or deformity. |No swelling or erythema. |Full ROM is noted in all joints. |Muscle strength is 5/5 b/l. |Tendon function is normal. |Cap refill is less than 3secs in all extremities. |Pulses palpable. |No peripheral vascular exam was performed. |No MSK exam was performed."]

Psych:
[textarea name="variable_29" default="Insert abnormalities or delete this text to remove."] [checkbox name="MSE" value="Appropriate mood and affect. |Adequate judgement and insight. |No visual or auditory hallucinations. |No SI or HI. |No parasuicidal thoughts or behavior. |MSE not performed."]


Labs:
[textarea name="variable_14"]

Imaging:
[textarea name="variable_14"]

Other:
[textarea name="variable_14"]



----------
ASSESSMENT
----------
[textarea name="variable_13"]

ICD-10 Diagnoses:
[textarea name="variable_14"]



----
PLAN
----
Treatment:
[textarea name="variable_14"]

Patient Education:
[textarea name="variable_15"]

Follow-Up:
[textarea name="variable_16"]



/e/Signed By: [text name="variable_30"] on [text name="variable_31"]

This form uses shorthand, to view it please click View > Edit Markup





Patient’s rights, confidentiality, limits/exceptions to confidentiality, and use of electronic medical records were reviewed with the patient. Verification of patient identity was established with the patient.

DATE:
CASE ID #

----------
SUBJECTIVE
----------
CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:
Patient is a presenting to w/ a chief complaint of .Patient denies any associated .Patient has no other complaints.


REVIEW OF SYSTEMS:
General:

Skin:

Head:

Eyes:

Ears:

Nose/Sinus:

Allergies:

Mouth/Throat:

Neck:

Breast:

Cardio:

Pulmonology:

GI:

Urinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic

Hematologic:

Endocrine:

Psychiatric:


PMHx:


Surg Hx:


Family Hx:


Medications:


Allergies:



---------
OBJECTIVE
---------
VITALS:
- HR:
- RR:
- BP:
- T:
- HT:
- WT:


PE FINDINGS:
General:


Neuro:


Integumentary:


HEENT:


Cardiopulmonary:


GI:


GU:


Peripheral Vascular/MSK:


Psych:



Labs:


Imaging:


Other:




----------
ASSESSMENT
----------


ICD-10 Diagnoses:




----
PLAN
----
Treatment:


Patient Education:


Follow-Up:




/e/Signed By: on

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