VA H&P Maker

Chief complaint: 
[text name="CC" default=""]
 
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History of Present Illness:
===========================
Mr. [text name="Name" default=""] is a [text name="Age" default=" "] year old male with a past medical history of [textarea name="PMH" default=""] who presents for [var name="CC"]

[textarea name="HPI" default=""]

ER Course:
Vital signs  [textarea name="vitals" default="have been stable"]. Initial workup revealed  [textarea name="Workup" default=""]

[select name="mod_1" value="CXR|CT|CTA|CT head|CT chest|CT abd/pelvis|MRI|US|XR|EKG"] showed [textarea name="image1" default=""]. [select name="mod_2" value="CXR|CT|CTA|CT head|CT chest|CT abd/pelvis|MRI|US|XR|EKG"] showed [textarea name="image2" default=""].  
Patient was given [textarea name="meds" default=""]

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Past Medical/Surgical History:
=============================
[textarea name="PSH" default=""]

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I have reviewed patient's Medical and Surgical history. 
 
MEDICATIONS: Medications are reconciled and documented under separate ADMISSION
MEDICATION RECONCILIATION note.

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Social History
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Tobacco use: 
[textarea name="Tobacco" default=""]
 
Alcohol use: 
[textarea name="ETOH" default="none/denies"]
 
Illicit drug use: 
[textarea name="Drug" default="none/denies"]
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Family History:
==============
[textarea name="FH" default=" "]

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Physical Exam:
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GENERAL:  No acute distress
HEENT: Pupils equally round  Oral mucous membrane moist and clear.
NECK: Soft & supple. Full range of motion (ROM). Neg thyromegaly,
CVS: Normal rate and regular rhythm. Normal S1 and S2 appreciated
LUNG: Clear to auscultation bilaterally. 
ABD: Soft, nondistended, nontender. Normoactive bowel sounds.
EXTREMITIES: no joint swelling or clubbing
NEURO: A&O x 4. No focal findings. 

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Pertinent Labs:
==============
[var name="Workup"]
[textarea name="Labs" default=""] 
 

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Imaging:
========
[var name="mod_1"]
[var name="image1"]
 
[var name="mod_2"]
[var name="image2"]
 
Echo
[textarea name="Echo" default=""] 

EKG
[textarea name="EKG" default="Sinus rhythm"] 

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Assessment/Plan
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[textarea name="AP" default=""]