[checkbox name="Q1" value="REVIEW OF SYSTEMS:|PHYSICAL EXAM:|MEDICAL DECISION MAKING:1|MEDICAL DECISION MAKING:2"][conditional field="Q1" condition="(Q1).is('REVIEW OF SYSTEMS:')"] In addition to that documented in the HPI above, the additional ROS was obtained: CONSTITUTIONAL: Denies fevers or chills EYES: Denies vision changes EARS/NOSE/MOUTH/THROAT: Denies sore throat CARDIOVASCULAR: Denies chest pain RESPIRATORY: Denies shortness of breath GASTROINTESTINAL: Denies vomiting or diarrhea GENITOURINARY: Denies painful urination MUSCULOSKELETAL: Denies recent trauma INTEGUMENTARY: Denies new rashes NEUROLOGICAL: Denies new numbness or tingling or weakness ENDOCRINE: Denies unexpected weight loss HEMATOLOGIC: Denies bleeding disorders [/conditional] [conditional field="Q1" condition="(Q1).is('PHYSICAL EXAM:')"]VS: I have reviewed the triage vital signs CONSTITUTIONAL: Well-nourished, well-developed, appears stated age EYES: PERRL, no conjunctival injection EARS/NOSE/MOUTH/THROAT: Normocephalic, atraumatic, neck supple without meningismus CARDIOVASCULAR: Regular rate and rhythm, warm, well-perfused extremities RESPIRATORY: Clear to auscultation bilaterally, unlabored respiratory effort GASTROINTESTINAL: Soft, non-tender, non-distended, no masses GENITOURINARY: Deferred MUSCULOSKELETAL: No gross deformities appreciated INTEGUMENTARY: Warm, dry. No rashes NEUROLOGICAL: Alert, CNs II-XII grossly intact, sensation and motor function of extremities grossly intact PSYCHIATRIC: Appropriate mood and affect [/conditional] [conditional field="Q1" condition="(Q1).is('MEDICAL DECISION MAKING:1')"] [comment memo="Brief Overview: Age, sex, chief complaint---Relevant symptoms and history---Abnormal vital signs---Complete in 1-2 sentences"][textarea columns=5 rows=15 fillable="true"]*** Overview ***[/textarea][comment memo="Initial Differential: Based on one-liner, Worst case, What can be ruled out by H&P"] [textarea columns=20 rows=15 fillable="true"]*** MOST LIKELY ***, the differential includes *** WORST CASE ***, and less likely *** RULED-OUT & REASONING ***. Initial Testing: *** Testing & Rationale *** Initial Treatments: *** Treatments & Rationale *** The patient’s concerns were acknowledged and addressed. They shared in the decision making of diagnostic studies and therapeutic interventions, with agreed-upon expectations and possible dispositions. Communicated the plan with nursing. [/conditional] [conditional field="Q1" condition="(Q1).is('MEDICAL DECISION MAKING:2')"] [comment memo="Re-Evaluation" memo_size="large" memo_style="bold" memo_color="red"] [comment memo="Paragraph 2 (Written after reviewing results and dispositioning)Final Therapy, Final Testing, Discrepancies, Final Differential, Aftercare" memo_style="italic"][date name="date3" default="timestamp"][textarea columns=20 rows=15 fillable="true"]Re-evaluation: ***Response to Therapies***. ***Final Testing and Results***. ***Final Differential***. ***Disposition*** [textarea default="An extensive conversation regarding return precautions and need for follow-up was discussed with the patient, who verbalized their understanding and agreed with the disposition. Prescribed medications use, side effects and warnings were addressed. Specific precautions regarding their illness, possible Red Flag symptoms to be aware of, and the need for close follow-up. The patient was discharged with reassuring vitals signs and stable condition. William Gatewood DO, PGY-2 Emergency Medicine Resident"][/textarea] [textarea columns=20 rows=15 fillable="true"]Treatment plan:****** Follow-up: ****** Return precautions: ****** Timeframe ******[/textarea] [/conditional]
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