Rash

Case ID # [text name="field_name" default="sample text"]
Date of Service: [text name="field_name" default="sample text"]

Patient Demographics
Age: [text name="field_name" default="sample text"]y.o
Gender: [select name="field_name" value="Male|Female|Other"]
Race: [select name="field_name" value="African American|Caucasian|Hispanic|Asian|Other"]

Clinical Information
Patient Type: [select name="field_name" value="New|Established"]
Time with Patient: [text name="field_name" default="sample text"] mins
Type of Visit: [select name="field_name" value="New|Annual|Interim|Episodic"]

SUBJECTIVE:
Chief complaint (CC): [text name="field_name" default="sample text"]

History of present illness (HPI): 
Patient is a [text name="field_name" default="sample text"] seen for [text name="field_name" default="sample text"]. Patient has a history of [text name="field_name" default="sample text"]

Patient reports[textarea name="field_name" default="sample text"] 

Patient is using [textarea name="field_name" default="sample text"]

Patient has used [textarea name="field_name" default="sample text"]
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PMH: 

General Health and Strength: 
[textarea name="field_name" default="sample text"]

Significant Childhood Illnesses:  
[textarea name="field_name" default="sample text"]

Major Adult Illnesses or Chronic Illnesses: 
[textarea name="field_name" default="sample text"]

--Possible exposures: [text name="field_name" default="sample text"]
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Medications:
[textarea name="field_name" default="sample text"]

Allergies/ADR: 
[textarea name="field_name" default="Name/Reaction"]
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Past surgical history (PSH): 
[textarea name="field_name" default="Date, Dx, Hospital, Complications"]

Social history
--Place of birth/childhood: [text name="field_name" default="sample text"] 
--Socioeconomic status: [text name="field_name" default="sample text"] 
--Education level: [text name="field_name" default="sample text"] 
--Places visited: [text name="field_name" default="sample text"]
--Places lived: [text name="field_name" default="sample text"]
--Diet: [text name="field_name" default="sample text"]
--Exercise: [text name="field_name" default="sample text"]
--Home Conditions: [text name="field_name" default="sample text"]
--Occupations: [text name="field_name" default="sample text"]
--Environment: [text name="field_name" default="sample text"]
--Military Record: [text name="field_name" default="sample text"]
--Smoking History: [text name="field_name" default="sample text"]
--Alcohol Use: [text name="field_name" default="sample text"]
--Illicit Drugs: [text name="field_name" default="sample text"]
--Sexual History: [text name="field_name" default="sample text"]
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Family history: 
--Mother: [text name="field_name" default="sample text"]
--Father: [text name="field_name" default="sample text"]
--Siblings: [text name="field_name" default="sample text"]
--Children: [text name="field_name" default="sample text"]
--Grandparents:[text name="field_name" default="sample text"]
--Aunts or Uncles: [text name="field_name" default="sample text"]
--Cousins: [text name="field_name" default="sample text"]
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Risks:
[textarea name="field_name" default="sample text"]
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Review of Systems: 

--Constitutional: c/o [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"] [text name="field_name" default="sample text"]. Denies: [checklist name="field_name" value="fatigue|fever|chills|malaise|generalized weakness|diffuse pain|sleeping problems|night sweats|weight changes"].
  
--Head: c/o [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="headaches|dizziness|syncope|dizziness|sinus pain|LOC"].

--Eyes: c/o  [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="vision loss|blurriness|blind spots|floaters|diplopia|photophobia|eye pain|halos|erythemia|drainage|change in appearance|dryness"].

--Ears: c/o [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent
infections"] [text name="field_name" default="sample text"]. [checklist name="field_name" value="ear pain|tinnitus|hearing loss|fullness in ears|drainage|drainage|vertigo|frequent
infections"].

--Nose: c/o [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="loss of smell|obstruction|epistaxis|drainage|congestion|tenderness|sinus pain|lesions"].

--Mouth and Throat: c/o [checklist name="field_name" value="hoarseness|change in voice B|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="hoarseness|change in voice|sore throat|bleeding in mouth|hemoptysis|swollen gums|recent abscess |recent extractions|soreness in mouth|soreness in tongue|ulcers|change in taste"]. 

--Neck: c/o [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="neck pain|stiffness|edema"] [text name="field_name" default="sample text"].

--Cardiac: c/o [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="chest pain|dyspnea| orthopnea|edema|palpitations|shortness of breath with activities|loss of consciousness|paroxysmal nocturnal dyspnea|need to elevate head at night due to SOB"].

--Vascular: c/o [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities|tendency to bruise"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="claudication|color changes in extremities|parathesias|coldness in extremities"].

--Respiratory: c/o [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="Pain with Respiration|Dyspnea|Cyanosis|Coughing|Wheezing|Sputum|Hemoptysis|Night Sweats|shortness of breath|exercise intolerance with activity"].

--Gastrointestinal: c/o [checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] [text name="field_name" default="sample text"]. Denies[checklist name="field_name" value="appetite changes|heartburn|dysphagia|abdominal pain|nausea|vomiting|diarrhea|constipation|change in stools|flatulence|anorexia|hematemesis |intolerance to foods|painful bowel movements|bloating|cramping|anorexia|bright red blood per rectum|foul smelling dark black tarry stools|tenesmus"] 

--Endocrine: c/o [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|
mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="thyroid tenderness|thyroid enlargement|excessive thirst|excessive hunger/excessive urination|heat intolerance|cold intolerance|unexplained Weight changes|changes in face or body hair|striae|increased hat or glove size|
mood swings|sweaty|diarrhea|oligomenorrhoea|tremor, palpitations|visual disturbances|feeling slow|feeling tired|depression thin hair| croaky voice|heavy periods|constipation|dry skin|orthostatic symptoms, darkening of skin in non-sun exposed places"].

--Hematological/Lymphatic: c/o [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="anemia|purpura|petechia| prolonged or excessive bleeding after dental extraction/injury|bruising|blood clots|enlarged lymph nodes|tender lymph nodes"].

--Genitourinary: c/o [checklist name="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="dysuria|urinary frequency|urinary urgency| hematuria|flank pain|suprapubic pain|nocturia|polyuria|dark or discolored Urine|hesitancy|terminal dribbling|loss of force of stream|loss or urine with laughing, coughing, sneezing, exercise, position changes|loss of sensation|loss of control"]
 
Reproductive (female): c/o [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in cycle duration and frequency|vaginal bleeding irregularities|vaginal discharge|vaginal pain|menstrual pain|changes in sexual arousal or libido|infertility|painful intercourse"]. Gravida [text name="field_name" default="sample text"] Para [text name="field_name" default="sample text"] Abortus [text name="field_name" default="sample text"]. LMP: [text name="field_name" default="sample text"].

Reproductive (male): c/o [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="difficulty with erection|difficulty with sexual arousal|lack of stamina|difficulty with emissions|testicular pain"].

--Musculoskeletal: c/o [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="joint pain or tenderness|joint swelling|muscles pain|ROM changes|stiffness |bony deformity|misalignment"].

--Integument:
c/o [checklist name="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"] [text name="field_name" default="sample text"]. Denies [checklist name="pruritis|rashes|stria|lesions|wounds|pigmentation changes|acanthosis nigricans|nodules|lumps/bumps|excessive dryness|discoloration|texture changes|eruptions"].

--Neurological: c/o [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="change in sight|changes in smell|change in hearing|changes in taste|change in sensation|faints|fits|funny turns|headache|paraesthesias|numbness|paralysis|limb weakness|poor balance|loss of coordination|speech problems|seizures|dizziness|headaches|tremors|memory loss"].

--Psychiatric: c/o [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges
|irritability|tension|suicidal thoughts|homicidal thoughts"] [text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="depression|change in sleep patterns|anxiety|difficulty concentrating|difficulty paying attention|change in body image|changes in work and school performance|paranoia|anhedonia|lack of energy|episodes of mania|episodic change in personality|sexual or financial binges
|irritability|tension|suicidal thoughts|homicidal thoughts"]

--Breasts: c/o [checklist name="field_name" value="breast pain/soreness|discharge|lumps"]
[text name="field_name" default="sample text"]. Denies [checklist name="field_name" value="breast pain/soreness|discharge|lumps"]
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OBJECTIVE:
PE:
--Vital signs: T[text name="field_name" default="sample text"] P[text name="field_name" default="sample text"] R[text name="field_name" default="sample text"] BP[text name="field_name" default="sample text"] O2 Sat [text name="field_name" default="sample text"] on [text name="field_name" default="sample text"]

--General Appearance: 
LOC:[checklist name="field_name" value="Alert|Awake|Aware|Asleep|Responds to Verbal Stimulus|Responds to Pain|Unresponsive |Lethargic|Unconscious"]
Gait: [text name="field_name" default="sample text"] 
Hygiene and Grooming:[text name="field_name" default="sample text"]
Affect:[text name="field_name" default="sample text"]
Nutrition: [checklist name="field_name" value="well-nourished|cachexic"]
Distress: [checklist name="field_name" value="observable pain cues|appears in no acute distress"]

--Hair/Skin/Nails:
Skin is [checklist name="field_name" value="pale|grey|flushed"] with 
[checklist name="patches of" value="brown|yellow|white|red"]/localized [checklist name="field_name" value="brown|white|red"]. Noted skin [select name="turgor shows" value="no tenting|mild tenting|tenting"]

[checklist name="Rash is a" value="localized|regional|generalized"] area that measures approximately [text name="field_name" default="sample text"]. 
[checklist name="with a color that is" value="option A|option B|option C"]
flesh colored|pink|erythematous|salmon|tan-brown|violaceous|yellow|white|silver. [checklist name=" Rash shape is" value="annular|round|discoid|zosteriform|polcyclic|linear|target|iris|stellate|serpiginous|reticulate|morbilliform"] with [checklist name="borders that are" value="discrete|indistinct|active|irregular|raised above center|advancing"] and [checklist name="associated changes of" value="clearing in the center|desquamation|keratotic|punctation|telangiectasias"]. There are [checklist name="secondary lesions of" value="macules|patches|papules|plaques|wheals|nodules|tumors|vesicles|bullae|pustules|cysts|crust|scale|excoriations|lichenification|erosions|fissures|petichiae|pupura|moist desquamation|dry desquamation|ulcers"] are flesh colored|pink|erythematous|salmon|tan-brown|black|pearly|purple|violaceous|yellow
white|silver"] in color [text name="field_name" default="sample text"].

Hair is [text name="field_name" default="sample text"] colored, [checklist name="field_name" value="fine|coarse|brittle|thin|dry."] in texture, and shows [checklist name="field_name" value="option A|option B|option C"]
no hair loss|male pattern baldness|hair loss  with inflammation|hair loss with scarring|hair loss with broken hair|hair loss with smooth skin. Body hair [checklist name="field_name" value="is decreased|increased|shows hirustism| is decreased on legs.
 
Inspected nails of [select name="field_name" value="hand|feet|hands and feet"].
Nails of the [select name="field_name" value="hands|feet][select name="are" value="normal appearance|discolored|have"] [select name="field_name" value="choice A|choice B|choice C"] with [checklist name="field_name" value= "Aldrich-Mees' lines|Beau's lines|Muehrcke's lines|Terry's nails|Lindsay's Nails|Acral lentiginous melanoma|Oil spot patches|yellow discoloration|cyanosis|Quitter's nail's|splinter hemorrhages|pitting|onychomycosis|Onycholysis"].

Monofilament for semmes-weinstein reveals [select name="field_name" value="right foot|left foot"] [text name="field_name" default="sample text"]/10 and [select name="field_name" value="right foot|left foot"] [text name="field_name" default="sample text"]/10

Wood's lamp shows [checklist name="field_name" value="sharp, clear borders with areas of blue white or yellow green|yellow or orange glow|blue green|coral pink|green in wound|orange red"]
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ASSESSMENT:
--VS:
[textarea name="field_name" default="sample text"]

Nurtition: Weight: [text name="field_name" default="sample text"] BMI: [text name="field_name" default="sample text"] Weight changes: [text name="field_name" default="sample text"]

--Pertinent lab values: 
[textarea name="field_name" default="sample text"]
--Pertinent diagnostic test results: 
[textarea name="field_name" default="sample text"]

Actual diagnosis:
[text name="field_name" default="sample text"]
DDx:
[textarea name="field_name" default="sample text"]
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PLAN: 
--On this visit: 
Procedures: 
[textarea name="field_name" default="sample text"], 
Purpose of Procedure: 
[textarea name="field_name" default="sample text"], 
Consent was [select name="field_name" value="obtained verbally|obtained written|not obtained"]

--Medications Discontinued:
[textarea name="field_name" default="sample text"]

--Medications Given: 
[textarea name="field_name" default="sample text"]

--Medication Refills:
[textarea name="field_name" default="sample text"]

--Medication Samples:
[textarea name="field_name" default="sample text"]

--Labs Ordered:
[textarea name="field_name" default="sample text"]

--Diagnostics Ordered:
[textarea name="field_name" default="sample text"]

--Referrals:
[textarea name="field_name" default="sample text"]

--Follow-up:
[textarea name="field_name" default="sample text"]

--Education Given:
[textarea name="field_name" default="sample text"]