DMC 4/12 Admission

Date of Visit: [date default="timestamp"]
Name:[text name="field_name_20" default=""]
MRN:[text name="field_name_1" default=""]
Age: [text name="field_name_2" default=""]y.o
Gender: [select name="field_name_21" value="Male|Female|Other"]
Race: [select name="field_name_4" value="African American|Caucasian|Hispanic|Asian|Other"]

Chief complaint: [text name="variable_2" default=""]

History of present illness:
Patient is a [text name="field_name_2" default=""] Year Old [select name="field_name_21" value="Male|Female|Other"] with [checkbox name="variable_1828" value="PMH of"] [textarea name="variable_3" default=""]
[checkbox name="variable_181" value="Patient also states that"][checkbox name="variable_4" value="he|she"] 
[checkbox name="variable_182" value="is also experiencing"] [checkbox name="variable_5" value="field_name" value="headache|fevers|chills|night sweats|light headedness|nausea|dizziness|vomiting|fatigue|cough|sob|dyspenia on exertion|PND|chest pain|palpitations|fainting|loc|weight loss|abdominal pain|dark stool|bloody stool|diarrhea|changes urination|dysuria|hematuria|muscle/joint pain|swelling|numbness|tingling| unusual rashes or lesions."]
[checkbox name="variable_6" value="No headache fevers, chills, night sweats, loss of consciousness, light headedness, nausea, dizziness, vomiting, fatigue, cough, sob, dyspenia on exertion, PND, chest pain, palpitations, fainting, loc, weight loss, abdominal pain, dark stool, bloody stool, diarrhea, changes urination, muscle/joint pain, swelling or unusual rashes or lesions."]
[checkbox name="variable_7" value="No"] [checkbox name="variable_8" value="headache|fevers|chills|night sweats|light headedness|nausea|dizziness|vomiting|fatigue|cough|SOB|loss of consciousness|dyspenia on exertion|PND|chest pain|palpitations|fainting|loc|weight loss|abdominal pain|dark stool|bloody stool|diarrhea|changes urination|muscle/joint pain|numbness|tingling|swelling|or unusual rashes or lesions."]

10 Point Review of Systems: Negative Except above.

ER Course: [textarea name="variable_18383" default="No interventions"]

PMH/Surgeries/Hospitalizations:[textarea name="variable_82" default="No PMH"]
Meds:[textarea name="variable_12" default="No Medications"]
Allergies:[textarea name="variable_13" default="No Known Drug Allergies"]
Social history:[checkbox name="variable_10" value="Denies toxic habits|History of ETOH abuse|Smokes cigarretes"][text name="variable_14" default=""]
Family history: [textarea name="variable_15" default="Non contributory"]

Physical Exam
Vital signs:[checkbox name="variable_5767" value="Reviewed and are within Normal Limits"]
[checkbox name="variable_73471" value="Except"]
[text name="variable_18976" default=""]
BP – [text name="variable_119" default=""]mm Hg
T - [text name="variable_110" default=""]F
HR - [text name="variable_111" default=""]bpm
RR - [text name="variable_112" default=""]brpm
SaO2 - [text name="variable_113" default=""]%

[textarea name="variable_22" default="GEN: NAD, WD/WN, HEENT: NC/AT, PERRL, NECK: no lad or JVD, CVS: RRR, nl S1/S2, no murmurs, 2+ pulses throughout; CHEST: CTAB, equal chest expansion.; ABD: NT/ND, BS+, no HSM, EXT: no peripheral edema or swelling"]
[checkbox name="variable_23" value="GA: No acute distress, lying in bed,WN/WD , appears stated age, AAOx3
HEENT: NC/AT, EOMI, PERRL, anicteric, oropharynx clear, mucous membranes moist
Neck: Supple, no LAD, JVP ~6-8cm
CHEST: Clear to auscultation bilaterally.  No wheezes/rhonchi/rales.  Equal chest expansion. No accessory muscle usage.
CVS:  RRR.  No murmurs, rubs or gallops.
ABD: Soft, NT/ND.  Normo-active bowel sounds.  No organomegaly or masses appreciated. 
Extremities: No clubbing, cyanosis, edema.  2+ DP pulses.
Neuro: Alert and oriented. CN 2-12  grossly intact,  Conversant, moving all extremities. Grossly non-focal. Strength intact all extremities. SILT and SIP intact in all extremities.  No overt cerebellar signs / incoordination, F2N intact,   no tremors."]

LABS:[checkbox name="variable_25" value="Reviewed"]
[checkbox name="variable_27" value="Significant Labs:"]
[textarea name="variable_49" default=""]
[checkbox name="variable_26" value="CBC: WBCs Hgb Hct Plts
CMP: Na K Cl HCO3 BUN Cr
Ca T Prot Alb AST ALT Alk Phos T Bili
Mg 
Ph
Troponin:
BNP
UA
BC
UC"]
[checkbox name="variable_48" value="pH: CO2:HCO3:PAO2"]
[checkbox name="variable_02307366" value=" Urinanalysis:"][textarea name="variable_3563" default=""]

[checkbox name="variable_08976" value="Microbiology:"][checkbox name="variable_089436" value="Blood Culture"]
[textarea name="variable_343" default=""]

EKG:[checkbox name="variable_0453" value=" Normal Sinus Rhythm"][text name="variable_31" default=""]

[checkbox name="variable_08343776" value="TTE:"]
[textarea name="variable_25486" default=""]

Radiology:[checkbox name="variable_4012" value="Chest Xray: WNL, No acute Pathology noted"][checkbox name="variable_241512" value="Head CT Scan: WNL, No acute Pathology noted, No bleeds"][checkbox name="variable_2453212" value="Cervical Spine: WNL, No acute Pathology noted"][checkbox name="variable_24545612" value="Chest CT Scan: WNL, No acute Pathology noted, No PE"][textarea name="variable_32" default=""]

Assessment & Plan
[text name="field_name_2" default=""] Year Old [select name="field_name_21" value="Male|Female|Other"] with [checkbox name="variable_1828" value="PMH of"] [textarea name="variable_3" default=""]


DVT ppx: [select name="field_name_4411" value="Lovenox|Heparin Sub Q|Xarelto|Eliquis|ICDs| Heparin Drip"]
Diet: [select name="field_name_4422" value="Heart Healthy Diet|Diabetic Diet|Renal Diet"]
Dispo: [select name="field_name_4243" value="HOME|NURSING HOME|SHELTER|SKILLED NURSING FACILITY"]
Code status: [select name="field_name_44" value="Full Code|DNR/DNI|DNI but not DNR|DNR but not DNR"]