DMC Discharge 10/19 b

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"]

Admission Diagnosis: [text name="variable_2" default=""]

Hospital course:
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."]
[checkbox name="variable_57682" value="Patient has remained afebrile throughout hospital stay and has resumed normal intake, urine output, and regular bowel movements."]
[checkbox name="variable_573682" value="Patient is hemodynamically stable and ready to be discharged."]
Plan discussed extensively with patient/family. Understanding was confirmed verbally. 

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




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."]

Discharge Instructions:

Medications:
[textarea name="variable_494939" default="No new medications"]
[checkbox name="variable_23142" value="New medication include"]
[textarea name="variable_34343509 default=""]


Follow-up with appointments:

[checkbox name="variable_34342988" value="PCP"]
[text name="variable_348329" default=""]
[textarea name="variable_3998493" default=""]


Return to emergency room if fever >100.4F, abdominal pains, changes in diet or activity, difficulty breathing, seizures, persistent vomiting, or any other concerns