Injury & Poisoning
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Motor Vehicle Accident
This was a [text] velocity impact. The vehicle impact was at the [text].
[select value="no|YES"] <-- Air bags deployed

Before the accident, the patient was seated [text] in relation to the vehicle.
Vehicle Restraints (e.g. seat belt): [text].
Extrication at the scene: [text]

[select value="no|YES"] <-- inside the vehicle after the accident.
[select value="no|YES"] <-- able to ambulate after the accident
[select value="no|YES"] <-- conscious during the accident
[select value="no|YES"] <-- remembers the impact
[select value="no|YES"] <-- remembers after the accident

Injury [text] prior to evaluation
Onset while: [text]
Episode location: [text]
Episode description: [text]




INJURY TO:
[checkbox name="body_part" value="head|scalp|face|jaw|mouth|tongue|neck|chest|abdomen|upper back|lower back|shoulder|elbow|forearm|hand/wrist|hip|buttocks|thigh|knee|lower leg|foot/ankle|"][textarea cols=70 rows=1]

IMMEDIATELY AFTER:
[checkbox name="after" value="LOC|dazed|confused|memory loss|dizziness|visual disturbance|remained inside vehicle|ambulated at scene|extricated by 911|police at scene|ambulance on scene|declined ER transport|taken to ER by ambulance|taken to ER by private transport|evaluated in ER|"][textarea cols=70 rows=1]

ASSOCIATED SX: [+] reported [-] not reported
[checklist name="associated" value="headache|trouble concentrating|dizziness|poor balance|memory loss|confusion|visual changes|sensory-motor loss|difficulty standing/walking|nausea|vomiting|bowel/bladder dysfunction|focal weakness"]

BASELINE AMBULATION/MOBILITY:
[checkbox name="ambulation" value="walks w/o assistance|uses cane|uses walker|uses wheelchair|stands for transfers|walks only w assistance|unable to sit|unable to walk|bed-ridden"][textarea cols=70 rows=1]

PAST & RECENT HISTORY:
[checkbox name="pmh" value="head injury|seizure disorder|previous injuries/accidents|chronic back pain|chronic pain meds|obesity|migraine|recent PCP visit|recent ER/UC visit|recent hospitalization|DM|HTN|CAD|CABG|pacemaker|CVA/TIA|anticoagulation|ETOH abuse|drug abuse|dementia|"][textarea cols=70 rows=1]

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL: [textarea cols=40 rows=1]
[checklist name="const_symptoms" value="fever|chills|weight loss"]
LEFT EAR: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|bleeding|tinnitus|changes in hearing|fluid discharge "]
RIGHT EAR: [textarea cols=40 rows=1]
[checklist name="ear_symptoms" value="pain|bleeding|tinnitus|changes in hearing|fluid disharge"]
[text name="variable_1" default="sample text"]
NOSE: [textarea cols=40 rows=1]
[checklist name="nose_symptoms" value="discharge|trauma|bleeding"]
MOUTH: [textarea cols=40 rows=1]
[checklist name="mouth_symptoms" value="trauma|bleeding|tongue pain/swelling|toothache|loose missing teeth"]
THROAT: [textarea cols=40 rows=1]
[checklist name="throat_symptoms" value="sore throat|dysphagia|hoarseness|fluids noted in airway"]
CV: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="chest pain/pressure|dyspnea|orthopnea|ankle discoloration|leg cramps"]
RESPIRATORY: [textarea cols=40 rows=1]
[checklist name="chest_symptoms" value="chest tightness|pain w/ breathing|cough"]
GI: [textarea cols=40 rows=1]
[checklist name="gi_symptoms" value="poor appetite|nausea|vomiting|abdominal pain|constipation|diarrhea|blood in stool"]
GU: [textarea cols=40 rows=1]
[checklist name="gu_symptoms" value="dysuria|urgency|odor|hematuria|retention|incontinence"]
PSYCH: [textarea cols=40 rows=1]
[checklist name="psych_symptoms" value="irritability|confusion|depression|anxiety|mood swings|memory loss"]
LYMPH/HEMA: [textarea cols=40 rows=1]
[checklist name="hem_symptoms" value="gland swelling|bruising|anticoagulation|DVT/clotting|anemia|cancer|HIV"]
DERM: [textarea cols=40 rows=1]
[checklist name="derm_symptoms" value="dryness|laceration|redness|swelling|wounds|bruise|bleeding"]

Appearance:
[checkbox name="appearance" value="well-appearing|no distress noted|alert & oriented x3|alert but disoriented to time| alert but confused|poor cooperation with exam|ill-appearing|drowsy|"][textarea cols=70 rows=1]


RIGHT EYE:[checkbox name="eyes" value="clear conjunctiva w/o hemorrhage, sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear|PERRL|glasses|conjunctival injection|subconjunctival hemorrhage|raccoon eyes|periorbital swelling|dysconjugate gaze|"][textarea cols=70 rows=1]
LEFT EYE:[checkbox name="eyes" value="clear conjunctiva w/o hemorrhage, sclera, EOM intact without nystagmus|visual acuity grossly intact|cornea(s) clear|PERRL|glasses|conjunctival injection|subconjunctival hemorrhage|raccoon eyes|periorbital swelling|dysconjugate gaze|"][textarea cols=70 rows=1]
[text name="variable_1" default="sample text"]


LEFT Ear:[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without clear or bloody liquid|TMs normal in appearance|"][textarea cols=70 rows=1]

RIGHT Ear:[checkbox name="ears" value="symmetrical & intact auricles bilaterally|hearing to conversation intact|clear canals without clear or bloody liquid|TMs normal in appearance|"][textarea cols=70 rows=1]

Nose:
[checkbox name="nose" value="nares patent bilaterally|septum midline|mucosa pink & moist|mucosal edema|clear discharge|active septal hemorrhage|clotted blood"][textarea cols=70 rows=1]

Mouth:
[checkbox name="mouth" value="normal inspection|moist oral mucosa without lesions or injury|no dental injury|upper denture|lower denture|mucosal laceration|dental injury|tongue deviation|dental decay|"][textarea cols=70 rows=1]

Throat:
[checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates|uvula midline|pharyngeal erythema w/o exudates|"][textarea cols=70 rows=1]

CV:
[checkbox name="cv" value="regular rhythm|no murmurs|no ankle edema|pedal skin warm with good & equal pulses|tachycardia|irregular heart rhythm|murmur|ankle edema|varicosities|stasis discoloration|"][textarea cols=70 rows=1]

Abdomen:
[checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds|soft non-tender|protruding|surgical scar|umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|"][textarea cols=70 rows=1]

GU:
[checkbox name="gu" value="not examined|no suprapubic tenderness|"][textarea cols=70 rows=1]

Skin:
[checkbox name="skin" value="warm, pink, and dry|normal turgor|tattoos|body piercings|rash|"][textarea cols=70 rows=1]

Head/Face:
[checkbox name="head" value="no apparent trauma|scalp non-tender|symmetrical face|CN grossly intact|no facial tenderness|scalp swelling|facial bruising|Battle sign"][textarea cols=70 rows=1]

NECK:
[checkbox name="neck" value="no gross deformity or misalignment|no vertebral tenderness|pain with movement|paravertebral muscle spasm|vertebral point-tenderness|"][textarea cols=70 rows=1]

Chest/Lungs:
[checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|non-tender|clear and equal breath sounds bilaterally|bruising|tenderness|poor effort|coughing|"][textarea cols=70 rows=1]

BACK:
[checkbox name="back" value="no gross deformity or misalignment|no vertebral tenderness|pain with movement|paravertebral muscle spasm|vertebral point-tenderness|"][textarea cols=70 rows=1]


LEFT ARM: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|bleeding|bruising|cuts/lacs/open areas notes"]
RIGHT ARM: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|bleeding|bruising|cuts/lacs/open areas notes"]
LEFT ELBOW:
[text name="variable_1" default="sample text"]
RIGHT ELBOW:
[text name="variable_1" default="sample text"]
LEFT LOWER ARM: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|dyspnea|bleeding|bruising|cuts/lacs/open areas notes|"]
RIGHT LOWER ARM: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|dyspnea|bleeding|bruising|cuts/lacs/open areas notes|"]


LEFT THIGH: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|dyspnea|bleeding|bruising|cuts/lacs/open areas notes|leg cramps"]
RIGHT THIGH: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|dyspnea|bleeding|bruising|cuts/lacs/open areas notes|leg cramps"]
LEFT KNEE:
[text name="variable_1" default="sample text"]
RIGHT KNEE:
[text name="variable_1" default="sample text"]
LEFT LOWER LEG: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|dyspnea|bleeding|bruising|cuts/lacs/open areas notes|leg cramps"]
RIGHT LOWER LEG: [textarea cols=40 rows=1]
[checklist name="cv_symptoms" value="pain/pressure|dyspnea|bleeding|bruising|cuts/lacs/open areas notes|leg cramps"]

UPPER EXTREMITY:
[checkbox name="ue_exam" value="no gross deformity or misalignment|shoulders non-tender|grip equal|pain with movement|muscle spasm|deformity|warmth, swelling|tenderness|abrasion|laceration|bruising|"][textarea cols=70 rows=1]

LOWER EXTREMITY:
[checkbox name="le_exam" value="no gross deformity or misalignment|pelvis stable|hips non-tender|heel/toe walk intact|pain with movement|muscle spasm|deformity|warmth, swelling|tenderness|abrasion|laceration|bruising|"][textarea cols=70 rows=1]

Neuro:
[checkbox name="neuro" value="normal concentration and attention|memory grossly intact|ambulates w/o limp or alteration in gait|balance & coordination grossly intact|"][textarea cols=70 rows=1]

Behavior:
[checkbox name="behavior" value="calm|pleasant|respectful|cooperative with exam|exam limited by urgency|exam limited by poor cooperation|exam limited by safety concerns|guarded|anxious|fearful|suspicious|hypervigilant|irritable|frustrated|restless|labile|sighing|crying|agitated|raising voice|defensive|argumentative|hostile|forceful|intense|euphoric|demanding particular medication, test, referral, or accommodation|withdrawn|indifferent|appears to be responding to internal psychotic process|"][textarea cols=70 rows=1]

Psychomotor Activity:
[checkbox name="psychomotor" value="no involuntary movements|tremor|tardive dyskinesia|tics|fidgeting|picking skin|twirling hair|cracking knuckles|threatening posture/movement|grimacing, furrowing eyebrows|tightening jaw|breathing hard|shaking extremities|clenching fists|intense staring|standing up and/or pacing|opening door to hallway"][textarea cols=70 rows=1]

Speech:
[checkbox name="speech" value="clear & coherent|normal rate & rhythm|slurred|monotonous|stuttering|hypoverbal|hyperverbal|loud|soft|slow|rapid|pressured|repetitive questions|cursing, swearing|criticisms of staff|verbal threats|expressive aphasia|receptive aphasia|"][textarea cols=70 rows=1]

Thought Process:
[checkbox name="thought_process" value="organized/linear/logical|circumstantial|tangential|perseveration|flight of ideas|preoccupation with illness|catastrophization|overgeneralization|unrealistic beliefs|negativism|pessimism|blaming others|staff splitting|delusions|paranoid ideation|"][textarea cols=70 rows=1]

EKG:
[checkbox name="ekg" value="no acute changes|abnormal|"][textarea cols=70 rows=1]


PLAN OF CARE:
[checkbox name="discussed" value="risks/benefits/side effects/alternatives discussed with patient/parent/SO, opportunity provided to ask questions|patient/parent/SO verbalized understanding of and agreement with POC."][textarea cols=70 rows=1]


TREATMENT:
[checkbox name="treat" value="|"][textarea cols=70 rows=1]


INSTRUCTED ON:
[checkbox name="instructions" value="|"][textarea cols=70 rows=1]

BARRIERS TO CARE:
[checkbox name="barriers" value="none identified|poor cooperation with exam|exam limited by affect/mental status|exam limited by pain|lack of motivation|incomplete history|vague shifting complaints|multiple comorbidities|polypharmacy|hostile/disruptive behavior|active psychiatric diagnosis|alcohol or substance use|social/cultural barriers|victim of abuse|"][textarea cols=70 rows=1]

DISPOSITION:
[checkbox name="disposition" value="transported to ER for immediate treatment via ambulance|declined emergency transfer|"][textarea cols=70 rows=1]

[textarea name="variable_1" default="sample text"]
Motor Vehicle Accident
This was a velocity impact. The vehicle impact was at the .
<-- Air bags deployed

Before the accident, the patient was seated in relation to the vehicle.
Vehicle Restraints (e.g. seat belt): .
Extrication at the scene:

<-- inside the vehicle after the accident.
<-- able to ambulate after the accident
<-- conscious during the accident
<-- remembers the impact
<-- remembers after the accident

Injury prior to evaluation
Onset while:
Episode location:
Episode description:




INJURY TO:


IMMEDIATELY AFTER:


ASSOCIATED SX: [+] reported [-] not reported


BASELINE AMBULATION/MOBILITY:


PAST & RECENT HISTORY:


REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI
CONSTITUTIONAL:

LEFT EAR:

RIGHT EAR:


NOSE:

MOUTH:

THROAT:

CV:

RESPIRATORY:

GI:

GU:

PSYCH:

LYMPH/HEMA:

DERM:


Appearance:



RIGHT EYE:
LEFT EYE:



LEFT Ear:

RIGHT Ear:

Nose:


Mouth:


Throat:


CV:


Abdomen:


GU:


Skin:


Head/Face:


NECK:


Chest/Lungs:


BACK:



LEFT ARM:

RIGHT ARM:

LEFT ELBOW:

RIGHT ELBOW:

LEFT LOWER ARM:

RIGHT LOWER ARM:



LEFT THIGH:

RIGHT THIGH:

LEFT KNEE:

RIGHT KNEE:

LEFT LOWER LEG:

RIGHT LOWER LEG:


UPPER EXTREMITY:


LOWER EXTREMITY:


Neuro:


Behavior:


Psychomotor Activity:


Speech:


Thought Process:


EKG:



PLAN OF CARE:



TREATMENT:



INSTRUCTED ON:


BARRIERS TO CARE:


DISPOSITION:


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