Tap Note 4

[select name="variable_1" value="1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100|101|102|103|104|105|106|107|108|109|110|111|112|113|114|115|116|117|118|119|120"] [select name="variable_2" value="yo|mo|do"] [select name="variable_3" value="male|female"] pmhx of [checkbox name="variable_4" value="Allergies|Anemia|Arthritis|Asthma|Atrial fibrillation|Autoimmune diseases|Cancer|Chronic back pain|Chronic bronchitis|Chronic dermatitis|Chronic fatigue syndrome|Chronic infections|Chronic kidney disease (CKD)|Chronic liver disease|Chronic migraines|Chronic obstructive pulmonary disease (COPD)|Chronic pain syndrome|Chronic sinusitis|Congestive heart failure (CHF)|Crohn's disease|Depression|Diabetes|Epilepsy|Fibromyalgia|Gastroesophageal reflux disease (GERD)|Heart disease|Hyperlipidemia|Hypertension|Irritable bowel syndrome (IBS)|Multiple sclerosis (MS)|Myocardial Infarction|Osteoarthritis|Osteoporosis|Parkinson's disease|Peptic ulcers|Rheumatoid arthritis|Sleep apnea|Stroke|Thyroid disorders|Ulcerative colitis"] comes to the ED w/ [checkbox name="variable_5" value="trauma|falls|fever|headache|shortness of breath|cough|rhinorrhea|congestion|chest pain|abdominal pain|nausea|vomiting|diarrhea|melena|hematochezia|dysuria|hematuria|urinary frequency|skin changes|p.o. issues|issues urinating|issues stooling|issues with ambulation"]. Their pain/symptom is [select name="variable_6" value="mild|moderate|severe"], located in [checkbox name="variable_7" value="L|R|bilateral| "] [checkbox name="variable_8" value="upper|lower| "] [checkbox name="variable_9" value="RUQ (Right Upper Quadrant)|LUQ (Left Upper Quadrant)|RLQ (Right Lower Quadrant)|LLQ (Left Lower Quadrant)|Lumbar|Cervical|Thoracic|Medial|Lateral|Central|Proximal|Distal|Anterior|Posterior|Parietal|Occipital"] [checkbox name="variable_10" value="Abdomen|Ankles|Arms|Back|Buttocks|Calves|Chest|Ears|Elbows|Eyes|Face|Feet|Groin|Hands|Head|Hips|Knees|Legs|Mouth|Neck|Nose|Pelvis|Shoulders|Spine|Thighs|Throat|Wrists"], [select name="variable_11" value="constant|intermittent"], [select name="variable_12" value="non-mediating|mediating"] with [select name="variable_13" value="rest| |medication"], associated with [checkbox name="variable_14" value="trauma|falls|fever|headache|shortness of breath|cough|rhinorrhea|congestion|chest pain|abdominal pain|nausea|vomiting|diarrhea|melena|hematochezia|dysuria|hematuria|urinary frequency|skin changes|p.o. issues|issues urinating|issues stooling|issues with ambulation"]. Started [select name="variable_15" value="randomly| "]. Denies [checkbox name="variable_16" value="trauma|falls|fever|headache|shortness of breath|cough|rhinorrhea|congestion|chest pain|abdominal pain|nausea|vomiting|diarrhea|melena|hematochezia|dysuria|hematuria|urinary frequency|skin changes|p.o. issues|issues urinating|issues stooling|issues with ambulation"].

As per HPI

[General: non-toxic, NAD
HEENT: NCAT, PERRL
Cardiac: RRR, no murmurs, 2+ peripheral pulses
Chest: CTA
Abdomen: soft, non-distended, bowel sounds present, no ttp, no rebound or guarding
Extremities: no peripheral edema, calf tenderness, or leg size discrepancies
Skin: no rashes
Neuro: AAOx4, 5+motor, sensory grossly intact
Psych: mood and affect appropriate]

Impression: [Age and Gender] pmhx of [***] comes to ED w/ [***]. Their symptoms and exam findings of [***] are concerning for [***].

Ordered [labs, imaging, medications] for diagnosis, management, and treatment.