[text name="variable_1"] presenting with [text name="variable_3"] for [text name="variable_4"].
Patient is [select name="variable_1" value="well-appearing, and non toxic overall|ill-appearing, in considerable distress|is stable but appears to be in pain"].
[textarea name="variable_5" default=""]
Differential diagnosis includes but is not limited to the following:
Initial plan of treatment reviewed with patient and includes: [checkbox name="variable_1" value="EKG|Labs|xray|CT|US"]
[comment memo="Include all pertinent test results, ie CT results, troponin, d-dimer, all re-examinations, all consults - timed, all nursing patient updates and any interventions - meds that were given and response to those meds, new discovered information, ie - family arrived and new information given"]
[textarea name="variable_2" default="ED course"]