[conditional field="xxx" condition="condition to test"] any text to display if condition is true [/conditional]This is a Historian: Recent: [-] day care/school attendance [-] sick siblings [-] travel [-] ER/UC visit [-] hospitalization [-] surgery/procedure [-] diagnostic/laboratory studies [-] specialty consults [-] new medications [-] ABX use HPI: Onset: Duration: Symptoms: Frequency: Provoked/made worse by/at: Current medications: PMH: IMMUNIZATION: REVIEW OF SYSTEMS CONSTITUTIONAL: [-] fever [-] chills [-] body aches [-] changed behavior [-] tired [-] fussy [-] thirst HEAD/FACE: [-] head injury [-] scalp swelling [-] facial pain [-] facial swelling Headache: EYES: EARS: Swelling Right ear: pain, pressure, wax NOSE: [-] discharge [-] PND [-] congestion [-] sinus pressure [-] snoring [-] bleeding [-] possible FB [-] trauma MOUTH: Right [-] sores [-] teething [-] infection [-] swelling [+] jaw pain THROAT: [-] sore throat [-] odynophagia [-] hoarseness [-] tightness [-] globus NECK: [-] pain [-] swelling [-] stiffness [-] swollen glands CV: [-] chest pain/pressure [-] sob [-] palpitations [-] lightheadedness [-] fainting Chest/Respiratory: [-] cough [-] phlegm [-] wheezing [-] pain w/ breathing [-] rib pain [-] breast swelling/lump [-] nipple discharge GI: [+] poor appetite [-] nausea[conditional field="xxx" condition="condition to test"] any text to display if condition is true [/conditional] [-] vomiting [-] bloating [-] heartburn [-] gas [-] food allergies [-] generalized abdominal pain [-] epigastric pain [-] periumbilical pain [-] hypochondrial pain [-] low abdominal pain [-] diarrhea [-] constipation [-] melena [-] rectal pain/itching [-] rectal bleeding [-] laxative use GU: [-] dysuria [-] burning [-] frequency [-] urgency [-] urine odor [-] blood in urine [-] flank pain radiating to groin [-] oliguria [-] discharge [-] itching [-] skin lesion(s)/rash [-] scrotal swelling [-] testicular pain MSK: [-] myalgias [-] localized muscle/soft tissue pain/swelling [-] arthralgias [-] localized joint pain/swelling [-] acute back pain [-] limping NEURO: [-] dizziness [-] focal weakness [-] blackouts [-] tingling/numbness [-] speech difficulty [-] seizures BEHAVIORAL: [-] tantrums [-] hitting others [-] speech delay [-] in special ed PSYCH: [-] h/o ψ [-] prior hospitalizations [+] current meds [-] ongoing stress [-] depressed [-] anxious [-] mood swings [-] sleep problems LYMPH/HEMA: [-] gland swelling [-] unusual bruising [-] blood disorder [-] anemia ALLERGIES/IMMUNE: [-] atopy [-] environmental allergies [-] asthma [-] food allergies [-] autoimmune dz DERM: no complaints SOCIAL STRESSORS: none identified OBJECTIVE Appearance: well-appearing, active, interactive, non-toxic, moist mucous membranes, age-appropriate behavior, ill-appearing Head: normocephalic, atraumatic, normal hair distribution Face: symmetrical, no evidence of trauma, no obvious cranial nerve deficits Eye(s): clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact, PERL Ear(s): Right symmetrical & intact auricles bilaterally, hearing to conversation intact, no FB visible in canals, TMs normal in appearance, , tragal tenderness, swelling of external auditory canal, cerumen in canal Nose: nares patent bilaterally, no facial swelling or discoloration, no facial tenderness, mucosa pink & moist Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements, moist oral mucosa without lesions, normal bucal mucosa, normal dentition for age Throat: normal voice, patent pharynx w/o swelling or exudates, swallows fluids without cough or chocking, uvula midline, clear pharynx w/o exudates Neck: supple Lungs: normal work of breathing, symmetrical chest expansion, no stridor audible, clear and equal breath sounds bilaterally Chest/CV: regular rhythm, no murmurs, pedal skin warm with good & equal pulses Abdomen: normal visual inspection, no distension, normal active bowel sounds throughout, soft non-tender GU: MSK: Upper extremity(s): Lower extremity(s): Neuro: alert, gait, balance & coordination grossly intact, normal speech/vocalization, full weight bearing, , antalgic gait Psych: appropriate to age/situation, normal concentration and attention, good eye contact Skin: grossly intact, no suspicious lesions, no rashes, no bruises, normal turgor OFFICE DIAGNOSTICS: Acute Otitis Externadiscussed with patient/SO, official report to follow PROCEDURE(S): ear lavage completed, canal clear, TM intact, no active bleeding, tolerated intervention well OUTSIDE ORDERS: none RELEASE/CLEARANCE: excuse from school FOLLOW UP: RTC as discussed during visit, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx PATIENT/SO INSTRUCTED/COUNSELED ON: vital signs, exam findings, office tests, outside laboratory/diagnostic studies, , OTC medicines and comfort measures for symptom control, keeping affected area clean and dry, appropriate f/u w PCP PLAN OF CARE: risks/benefits/side effects/alternatives of/to proposed plan of care/medication(s) discussed with parent, opportunity provided to ask questions and state concerns DISCHARGE CONDITION: DISPOSITION: home TOTAL FACE-TO-FACE TIME: less than 30 minutes
There are 2 form elements.
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Sandbox Metrics: Structured Data Index 0, 2 form elements, 754 boilerplate words, 2 conditionals
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