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"] -------------------------------------------------------------------------------------------- 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"] -------------------------------------------------------------------------------------------- Medications: [textarea name="field_name" default="sample text"] Allergies/ADR: [textarea name="field_name" default="Name/Reaction"] ---------------------------------------------- --------------------------------------------- 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"] -------------------------------------------------------------------------------------------- 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"] -------------------------------------------------------------------------------------------- Risks: [textarea name="field_name" default="sample text"] ---------------------------------------------- ---------------------------------------------- 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"] ============================================================================================ 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"] ============================================== 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"] ============================================== 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"]
Result - Copy and paste this output:
Sandbox Metrics: Structured Data Index 0.41, 170 form elements, 370 boilerplate words, 75 text boxes, 25 text areas, 59 check lists, 11 drop downs, 623 total clicks
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