PCM Write Up

Identifying Data
Date:
[date name="variable_1" default="09/08/2020"]
Source:
[text name="variable_2" default="sample text"], [select name="variable_3" value="reliable|unreliable"],[text name="variable_4" default="location"]
Language:
[text name="variable_5" default="sample text"] used
Chief Compaint:
"[textarea name="variable_6" default="Sample text"]" x[text name="variable_7" default="#"] [select name="variable_8" value="hours|days|weeks|months"] 

History of Present Illness:
[textarea name="variable_18" default="Character,Location,Onset,Duration,Intensity,Exacerbation,Remission,Radiation,Setting,Social/Psych,Associated Symptoms,Explanation,Treatments,Healers"]
Past Medical History:
Hospitalizations/Surgery:
[text name="variable_19" default="date"]-[textarea name="variable_20" default="reason/procedure"],[select name="variable_21" value="non-complicated|complicated"]
Injuries/Accidents: [text name="variable_22" default="date"]-[textarea name="variable_23" default="sample text"]
Major Illnesses:
Childhood Diseases: +[checkbox name="variable_24" value="Measles|Mumps|Rubella|Chicken Pox|Rheumatic Fever"] [text name="variable_25" default="sample text"]. 
Denies [checkbox name="variable_26" value="Measles|Mumps|Rubella|Chicken Pox|Rheumatic Fever"] [text name="variable_27" default="sample text"]
Adult Disease: +[checkbox name="variable_27" value="Hypertension|Coronary Artery Disease|COPD|Asthma|DM|Hyperlipidemia"] [text name="variable_28" default="sample text"]. 
Denies [checkbox name="variable_29" value="Hypertension|Coronary Artery Disease|COPD|Asthma|DM|Hyperlipidemia"] [text name="variable_30" default="sample text"].

OB/GYN:
Gynecologic:[text name="variable_9" default="menarche"]x[text name="variable_10" default="frequency"]x[text name="variable_11" default="length of flow"],[select name="variable_12" value="light flow|moderate flow|heavy flow"]. LMP, [date name="variable_28" default="09/08/2020"]. The results of her last PAP test were [select name="variable_33" value="negative|positive|inconclusive"] ([text name="variable_34" default="date"]). The results of her last mammogram test were [select name="variable_35" value="negative|positive|inconclusive"] ([text name="variable_36" default="date"]).
Obstetric: G[text name="variable_13" default="#"]P[text name="variable_14" default="#"]F[text name="variable_15" default="#"]A[text name="variable_16" default="#"]L[text name="variable_17" default="#"].[text name="variable_37" default="#"] [select name="variable_38" value="uncomplicated vaginal deivery|complicated vaginal delivery"], [text name="variable_39" default="#"] [select name="variable_40" value="uncomplicated C-section|complicated C-section"].[select name="variable_41" value="Unremarkable|Event"] pregnancy.
Menopause: [select name="variable_29" value="N/A|Peri-menopausal|Post-menopausal"], at [text name="variable_30" default="Age"]-years-old, with [text name="variable_31" default="symptoms"].[select name="variable_32" value="denies postmenopausal bleeding|postmenopausal bleeding"].
Psychiatric: [select name="variable_42" value="Denies any psychiatric illness or treatment|Treated for|Untreated"]
Transfusions: [select name="variable_43" value="Denies transfusion history|Transfusion on"]
Current Medications:
[textarea name="variable_44" default=",mg qd/bd"]
Allergies:
Medication:[text name="variable_45" default="sample text"]
Food:[text name="variable_46" default="sample text"]
Enivronmental: [text name="variable_47" default="sample text"]
Family History: 
[textarea name="variable_48" default="Cancer: DM: HTN: DL:"]
Current Health/Risk Factors
Nutrition: [textarea name="variable_49" default="sample text"]
Smoking: 
[textarea name="variable_50" default="sample text"]
Alcohol: [textarea name="variable_51" default="CAGE"]
Other Drugs: [textarea name="variable_52" default="sample text"]
Sleep: [textarea name="variable_53" default="sample text"]
Health Exams: [textarea name="variable_54" default="sample text"]
Immunizations: [textarea name="variable_55" default="sample text"]
Injury Prevention: [textarea name="variable_56" default="sample text"]
Chemoprophylaxis: [textarea name="variable_57" default="sample text"]
Social History
Personal Status: [textarea name="variable_58" default="sample text"]
Culture/Religion: [textarea name="variable_59" default="sample text"]
Support System: [textarea name="variable_60" default="sample text"]
Socioeconomic Data: [select name="variable_61" value="Has health insurance|No insurance"], [select name="variable_62" value="has transportation to appointments|does not have transportation to appointments"], [select name="variable_63" value="able to afford medications|unable to afford medications"]
Domestic Violence: textarea name="variable_64" default="HITS"]
Occupation: [textarea name="variable_65" default="sample text"]
Sexual Behavior: First intercourse at[text name="variable_66" default="age"] y/o, 
[text name="variable_67" default="#"] life-time partners, engages in sex with [select name="variable_68" value="men|women|both men and women"]. [textarea name="variable_69" default="STI, birth control"]
Military Record: [text name="variable_70" default="sample text"]
Travel: [textarea name="variable_71" default="sample text"]
Review of Systems
General: +[textarea name="variable_72" default="sample text"]. Denies [checkbox name="variable_73" value="fatigue|fever|chills|weight change|weakness"] 
[textarea name="variable_74" default="sample text"].
Skin: +[textarea name="variable_75" default="sample text"]. Denies [checkbox name="variable_76" value="rashes|color changes|itching|lumps|changes in hair/nails"] [textarea name="variable_77" default="sample text"].
HEENT: +[textarea name="variable_78" default="sample text"]. Denies [checkbox name="variable_79" value="headaches|head injury|dizziness|syncope|changes in vision|changes in hearing|discharge from eyes|ear pain|vertigo|nasal congestion|hay fever|epistaxis|sinus pain|changes in sense of smell|hoarseness|sore throat|changes in taste or oral pain"][textarea name="variable_80" default="sample text"].
Neck:+[textarea name="variable_81" default="sample text"]. Denies [checkbox name="variable_82" value="tender |swollen lymph nodes|masses|or neck pain"][textarea name="variable_83" default="sample text"].
Breast:+[textarea name="variable_84" default="sample text"]. Denies [checkbox name="variable_85" value="pain|tenderness |lumps"]
[textarea name="variable_86" default="sample text"].
Respiratory:+[textarea name="variable_87" default="sample text"]. Denies [checkbox name="variable_88" value="cough|wheezing|pleurisy"][textarea name="variable_89" default="sample text"].
Cardiac:+[textarea name="variable_90" default="sample text"]. Denies [checkbox name="variable_91" value="chest pain|edema|palpitation|dyspnea"][textarea name="variable_92" default="sample text"].
GU:+[textarea name="variable_93" default="sample text"]. Denies [checkbox name="variable_94" value="polyuria|dysuria|nocturia|urgency|hesitancy|discharge|itching|burning|incontinence|vaginal dryness|decreased sexual interest|pain during intercourse|dysmenorrhea"][textarea name="variable_95" default="sample text"].
GI:+[textarea name="variable_96" default="sample text"]. Denies [checkbox name="variable_97" value="cramping|nausea|vomiting|appetite decrease|diarrhea|constipation|hematochezia|melena|hematemesis|dysphagia|excessive belching|excessive flatulence"] [textarea name="variable_98" default="sample text"].
Musculoskeletal:+[textarea name="variable_99" default="sample text"]. Denies [checkbox name="variable_100" value="joint pain|stiffness|swelling|redness|muscle pain|weakness|muscle cramps"] [textarea name="variable_101" default="sample text"].
Neurologic:+[textarea name="variable_102" default="sample text"]. Denies [checkbox name="variable_103" value="paralysis|numbness|tremors|abnormal sensations|memory loss|seizures"] [textarea name="variable_104" default="sample text"].
Hematologic:+[textarea name="variable_105" default="sample text"]. Denies [checkbox name="variable_106" value="easy bleeding|easy bruising"] [textarea name="variable_107" default="sample text"].
Endocrine:+[textarea name="variable_108" default="sample text"]. Denies [checkbox name="variable_109" value="excessive sweating, thirst, hunger|heat or cold intolerance"] [textarea name="variable_110" default="sample text"].
Psychiatric:+[textarea name="variable_111" default="sample text"]. Denies [checkbox name="variable_112" value="anxiety|irritability|sleep disturbances|suicidal ideation|suicidal attempts"]
[textarea name="variable_113" default="sample text"].
Physical Exam
Vitals: T:[text name="variable_114" default="sample text"] P:[text name="variable_115" default="sample text"] BP:[text name="variable_116" default="sample text"]/[text name="variable_117" default="sample text"] RR:[text name="variable_118" default="sample text"] H:[text name="variable_119" default="sample text"] W:[text name="variable_120" default="sample text"] BMI: [text name="variable_121" default="sample text"]

General Appearance: [textarea name="variable_122" default="sample text"]
Head: [select name="variable_123" value="Normocephalic, atraumatic|"][select name="variable_125" value=", symmetrical face|, right facial droop|, left facial droop"] [text name="variable_126" default=""]
Eyes: [select name="variable_127" value="PERRLA|Anisocoria|Fixed pupils|Unreactive to light only|Unreactive to accommodation only|"], [select name="variable_128" value="EOMI|dysconjugate gaze|strabismus|horizontal nystagmus|vertical nystagmus|torsional nystagmus|mixed nystagmus|4th n. palsy|6th n. palsy|"], [select name="variable_129" value="conjunctiva clear|conjunctival congestion|conjunctival chemosis|conjunctival exudates|conjunctival icterus|conjunctival pallor|subconjunctival hemorrhage|"] [select name="variable_130" value=", bilateral|, left|, right|"] [select name="variable_131" value="normal eyelids|retracted eyelid|ptosis|palpebral swelling|"] [text name="variable_131" default=""]
Ears: [select name="variable_132" value="Bilateral|Left|Right"] [select name="variable_133" value="external auditory canal clear|eythematous external canal|swollen external canal|erythematous and swollen external canal"][select name="variable_134" value="|, bilateral|, left|, right"] [select name="variable_135" value="|tympanic membrane clear|bulging tympanic membrane|retracted tympanic membrane"][select name="variable_136" value="|, bilateral|, left|, right"] [select name="variable_137" value="|absent tragal tenderness|tragal tenderness"][select name="variable_138" value="|, bilateral|, left|, right"][select name="variable_139" value="|absent mastoid tenderness|mastoid tenderness"][select name="variable_140" value="|, bilateral|, left|, right"] [select name="variable_141" value="|hearing grossly intact|sensorineual hearing loss|conductive hearing loss|mixed hearing loss"] [text name="variable_142" default=""]
Nose: [select name="variable_143" value="No nasal discharge|Clear rhinorrhea|Purulent discharge|Epistaxis/Blood per nostril|"][select name="variable_144" value="|, normal nasal mucosa|pale, swollen mucosa|, bluish, swollen mucosa"]. [select name="variable_145" value="|No septal deviation|Septal deviation present"]. [select name="variable_146" value="|No septal perforation|Septal perforation present"]. [text name="variable_147" default=""]
Mouth/Throat: select name="variable_148" value="Oropharynx clear|Erythematous oropharynx|Purulent oropharynx|"], [select name="variable_149" value="moist mucosa|dry mucosa|"], [select name="variable_150" value="normal colored oral mucosa|pale oral mucosa|cyanotic oral mucosa|"] [text name="variable_151" default="sample text"]
Neck: [select name="variable_152" value="Supple|Stiff|Torticollis|"], [select name="variable_153" value="no cervical lymphadenopathy|left cervical lymphadenopathy|right cervical lymphadenopathy|bilateral cervical lymphadenopathy|"][select name="variable_154" value="|, left|, right|, bilateral|, diffuse|, total|, "] [select name="variable_155" value=" no thyromegaly|thromegaly|thyroid nodule|thyroid mass|hemithyroidectomy|thyroidectomy"] [select name="variable_156" value="with no tenderness|with tenderness|."]
Cardiac: [select name="variable_157" value="Normal rate and rythm|Tachycardiac|Bradycardiac|Small, weak pulse|Large bounding pulse|Bisferiens pulse|Pulsus alternans|Bigeminal pulse|Pulsus paradoxicus|"], [select name="variable_158" value="normal S1, S2|wide splitting|fixed splitting|paradoxical splitting|3rd heart sound|4th heart sound|"], [select name="variable_159" value="no murmurs, rubs, or gallops|early systolic murmur|mid systolic (ejection) murmur|late systolic murmur|pan systolic murmur|early diastolic murmur|late diastolic mumrmur|presystolic murmur|continuous murmur|pericardial rub|gallop|"] [text name="variable_160" default=""], capillary refill [text name="variable_161" default="seconds"], [select name="variable_162" value="no carotid bruit|carotid bruit"].[select name="variable_163" value="No peripheral edema|Pitting edema"], [select name="variable_164" value="no cyanosis or pallor|cyanois|pallor|cyanosis and pallor"],extremities are [select name="variable_165" value="warm and well perfused|cold and clammy"]
[textarea name="variable_166" default="sample text"].
Respiratory: [select name="variable_167" value="Clear to auscultation (normal vesicular breath sounds)|Bronchial breath sounds|Diminished breath sounds"], [select name="variable_168" value="bilaerally|right upper lung field|left upper lung field|right lower lung field|left lower lung field"],