Complete Note
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Last visit: [text name="variable_56" default=""]
Chief complaint: [text name="variable_1" default=""]
History of present illness:
[textarea name="variable_1" default=""]

Review of systems:
General: reports [checkbox name="variable_1" value="fever/chills|fatigue|malaise|weight changes"]
HEENT: reports [checkbox name="variable_2" value="headaches|vision changes|changes in hearing|rhinorrhea|sore throat"]
Cardiac: reports [checkbox name="variable_3" value="chest pain|palpitations|peripheral edema"]
Pulmonary: reports [checkbox name="variable_4" value="shortness of breath|dyspnea| cough|sputum production"]
GI: reports [checkbox name="variable_5" value="nausea/vomiting|abdominal pain| diarrhea|constipation|hematochezia|melena"]
GU: reports [checkbox name="variable_6" value="dysuria|hematuria|flank pain"]
MSK: reports [checkbox name="variable_7" value="weakness|numbness|tingling"]
Integumentary: reports [checkbox name="variable_8" value="rashes"]
Neurologic: reports [checkbox name="variable_9" value="seizures"]
Psychiatric: reports [checkbox name="variable_10" value="depression|anxiety|suicidal ideation|homicidal ideation"]
Endocrine: reports [checkbox name="variable_11" value="polyphagia|polydipsia| polyuria"]
Hematologic: reports [checkbox name="variable_12" value="pallor|abnormal bleeding|abnormal bruising"]

Past medical history:
[textarea name="variable_3" default=""]

Past surgical history:
[textarea name="variable_56" default=""]

Allergies:
[textarea name="variable_4" default=""]

Medications:
[textarea name="variable_5" default=""]

Pharmacy:
[textarea name="variable_57" default=""]

Social history:
Occupation - [text name="variable_41" default=""]
Living situation - [text name="variable_40" default=""]
Social services - [text name="variable_42" default=""]
Tobacco - [text name="variable_6" default=""]
Alcohol - [text name="variable_7" default=""]
Illicit drugs - [text name="variable_8" default=""]

Family history:
[text name="variable_58" default=""]

Vital signs:
BP – [text name="variable_9" default=""]mm Hg
T - [text name="variable_10" default=""]F
HR - [text name="variable_11" default=""]bpm
RR - [text name="variable_12" default=""]brpm
SaO2 - [text name="variable_13" default=""]%

Physical examination
General: NAD, AAOx3
HEENT: NC/AT, PERRLA/EOMI, mmm, no LAD
Cardiovascular: RRR, +s1, +s2, no M/R/G
Pulmonary: CTA b/l, no W/R/R
Abdominal: soft, NT/ND, +bowel sounds, no organomegaly
MSK/Extremities: 5/5 muscle strength in UE & LE
Neurological: CN 2-12 intact, sensation intact, normal reflexes

Laboratory values:
CBC w/ diff:
WBCs[text name="variable_15" default=""], Hgb[text name="variable_16" default=""], Hct[text name="variable_17" default=""], Plts[text name="variable_18" default=""]

CMP:
Na[text name="variable_19" default=""] K[text name="variable_20" default=""] Cl[text name="variable_21" default=""] HCO3[text name="variable_22" default=""] BUN[text name="variable_23" default=""] Cr[text name="variable_24" default=""] Glu[text name="variable_25" default=""]
Ca[text name="variable_26" default=""] T Prot[text name="variable_27" default=""] Alb[text name="variable_28" default=""] AST[text name="variable_29" default=""] ALT[text name="variable_30" default=""] Alk Phos[text name="variable_31" default=""] T Bili[text name="variable_32" default=""]

Coags:
PT[text name="variable_33" default=""], INR[text name="variable_34" default=""], aPTT[text name="variable_35" default=""]

Other labs:
[text name="variable_59" default=""]

Radiology:
[textarea name="variable_36" default=""]

Microbiology:
[textarea name="variable_37" default=""]

Assessment
[textarea name="variable_38" default=""]

Plan
[textarea name="variable_39" default=""]

Health maintenance
Cancer screening:
- Colonoscopy: [text name="variable_43" default=""]

Vaccinations:
- Flu vaccine: [text name="variable_44" default=""]
- Pneumococcal (PPSV23/13): [text name="variable_45" default=""]
- Tdap: [text name="variable_46" default=""]

For females:
- Mammogram: [text name="variable_47" default=""]
- FRAX/QFracture Score: (If FRAX Score > 10%, get DEXA scan for osteoporosis); https://qfracture.org/ [text name="variable_48" default=""]
- Refer to Gyn for PAP smear if 21 or above: [text name="variable_49" default=""]

Other:
- ASCVD Score: (if >7.5, start high intensity statin; if >10, add ASA) [text name="variable_50" default=""]
- PPD/Quantiferon (if high risk for TB, i.e, jail, homeless/lives in shelter, recent TB exposure): [text name="variable_51" default=""]

For diabetics:
- Refer to Ophthalmology for Glaucoma Screening/Diabetic Retinopathy if with h/o DM: [text name="variable_52" default=""]
- Refer to Podiatry for Podiatry Diabetic Foot Screening if with h/o DM: [text name="variable_53" default=""]

For smokers:
- If 55-80 y/o who have a 30 pack-year smoking history & currently smoke or have quit w/in the past 15 years, LDCT: [text name="variable_54" default=""]
- >65 with h/o Smoking, send for US Abdomen for AAA screening: [text name="variable_55" default=""]

Counseling given on:
- Smoking and alcohol cessation and abstaining from substance abuse
- Driving with a seatbelt
- Safe sex practices
- Regular exercise, i.e., low impact, stationary bike, swimming
- Medication compliance
- Weight reduction
- Dietary counseling: low-fat diet, decrease whole dairy products (whole milk, cheese, and butter), fatty meats, and fried foods. Eat more fruits, vegetables, whole-wheat breads, lean chicken, and fish (such as salmon or tuna). Attempt at counting calories, use a calorie tracker such as MyFitnessPal, strive for 2700 kcal per day, small frequent meals, and avoid concentrated sweets.
Last visit:
Chief complaint:
History of present illness:


Review of systems:
General: reports
HEENT: reports
Cardiac: reports
Pulmonary: reports
GI: reports
GU: reports
MSK: reports
Integumentary: reports
Neurologic: reports
Psychiatric: reports
Endocrine: reports
Hematologic: reports

Past medical history:


Past surgical history:


Allergies:


Medications:


Pharmacy:


Social history:
Occupation -
Living situation -
Social services -
Tobacco -
Alcohol -
Illicit drugs -

Family history:


Vital signs:
BP – mm Hg
T - F
HR - bpm
RR - brpm
SaO2 - %

Physical examination
General: NAD, AAOx3
HEENT: NC/AT, PERRLA/EOMI, mmm, no LAD
Cardiovascular: RRR, +s1, +s2, no M/R/G
Pulmonary: CTA b/l, no W/R/R
Abdominal: soft, NT/ND, +bowel sounds, no organomegaly
MSK/Extremities: 5/5 muscle strength in UE & LE
Neurological: CN 2-12 intact, sensation intact, normal reflexes

Laboratory values:
CBC w/ diff:
WBCs, Hgb, Hct, Plts

CMP:
Na K Cl HCO3 BUN Cr Glu
Ca T Prot Alb AST ALT Alk Phos T Bili

Coags:
PT, INR, aPTT

Other labs:


Radiology:


Microbiology:


Assessment


Plan


Health maintenance
Cancer screening:
- Colonoscopy:

Vaccinations:
- Flu vaccine:
- Pneumococcal (PPSV23/13):
- Tdap:

For females:
- Mammogram:
- FRAX/QFracture Score: (If FRAX Score > 10%, get DEXA scan for osteoporosis); https://qfracture.org/
- Refer to Gyn for PAP smear if 21 or above:

Other:
- ASCVD Score: (if >7.5, start high intensity statin; if >10, add ASA)
- PPD/Quantiferon (if high risk for TB, i.e, jail, homeless/lives in shelter, recent TB exposure):

For diabetics:
- Refer to Ophthalmology for Glaucoma Screening/Diabetic Retinopathy if with h/o DM:
- Refer to Podiatry for Podiatry Diabetic Foot Screening if with h/o DM:

For smokers:
- If 55-80 y/o who have a 30 pack-year smoking history & currently smoke or have quit w/in the past 15 years, LDCT:
- >65 with h/o Smoking, send for US Abdomen for AAA screening:

Counseling given on:
- Smoking and alcohol cessation and abstaining from substance abuse
- Driving with a seatbelt
- Safe sex practices
- Regular exercise, i.e., low impact, stationary bike, swimming
- Medication compliance
- Weight reduction
- Dietary counseling: low-fat diet, decrease whole dairy products (whole milk, cheese, and butter), fatty meats, and fried foods. Eat more fruits, vegetables, whole-wheat breads, lean chicken, and fish (such as salmon or tuna). Attempt at counting calories, use a calorie tracker such as MyFitnessPal, strive for 2700 kcal per day, small frequent meals, and avoid concentrated sweets.
Result - Copy and paste this output: