F4
CAUTION: This page needs to be reviewed and categorized.Date of Visit [date name="variable_1" default="00/00/20--"] Age:[text name="Value_Generic" size="5"] Gender: [select name="variable_1" value="Female|Male"] Race:[select name="variable_2" value="Caucasian|Asian|Black|Hispanic|Native American|Other"] HPI: [text name="variable_3" default="OLDCARTS"] [checkbox name="Factors" value="nothing makes it better|nothing makes it worse|"] Treatment[checklist name="Treatment" value="None|ibuprofen|rest|ice|elevation|cough syrup|cold medicine|and|with"][textarea name="Details" cols="1" rows="4"] Allergies:[checkbox name="Allergies: " value="NKDA|include"][text name= " variable_5" default="sample text"] Medications:[checkbox name="Medications: " value="no daily medications|reviewed list in EMR|occasional tylenol or ibuprofen|no antibiotics in the past 3 months"] Supplements:[checklist name="Supplements:" value="Multivitamin|probiotics|none"]Tetanus Vaccination[radio name="TetanusVaccination" value="status unknown|less than 5 years ago|more than 5 years ago"] REVIEW OF SYSTEMS: General: [checklist name="General" value="fever|fatigue|night sweats|change in appetite|change in weight"] Skin: [checklist name="Skin" value="rash|itching|change in hair/nails"] Head: [checklist name="Head" value="headache|head injury"] Eyes: [checklist name="Eyes" value="change in vision|eye pain|double vision|flashing lights|corrective lenses"] Ears: [checklist name="Ears" value="change in hearing|ear pain|discharge|ringing|dizziness"] Nose/Sinus: [checklist name="NoseSinus" value="nose bleeds|congestion|frequent colds|sinus infections"] Allergies: [checklist name="Allergies" value="hives|swelling of lips/tongue|hay fever|asthma|eczema|sensitivity to drugs, foods, pollens, or dander"] Mouth/Throat: [checklist name="MouthThroat" value="bleeding gums|sore throat|sore tongue|pain in mouth|sores in mouth|hoarseness"] Neck: [checklist name="Neck" value="lumps|swollen glands|goiter|stiffness"] Breast: [checklist name="Breast" value="lumps|pain|nipple discharge"] Cardio: [checklist name="Cardio" value="chest pain|palpitations|heart murmur|history of heart medications|rheumatic heart disease|high blood pressure|high cholesterol|change in color of fingers or toes|swelling in hands or feet"] Pulmonology: [checklist name="Pulm" value="shortness of breath|cough|production of phlegm|coughing up blood|bronchitis|emphysema|COPD"] GI: [checklist name="GI" value="problems swallowing|heartburn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|excessive belching|excessing flatus|food intolerance|rectal bleeding|hemorrhoids|yellowing of skin"] Urinary: [checklist name="Urinary" value="difficulty in urination|pain or burning with urination|frequent urination at night|urgent need to urinate|incontinence of urine|dribbling|decreased urine stream|blood in urine|UTI|stones|prostate issues"] Peripheral Vascular: [checklist name="PeripheralVascular" value="leg cramps|varicose veins|clots in veins"] Musculoskeletal: [checklist name="MSK" value="pain|swelling|stiffness|decreased range of motion|broken bone|serious sprains|arthritis|gout"] Neurologic [checklist name="Neuro" value="headaches|migraines|seizures|loss of consciousness/fainting|paralysis|weakness|muscle spasm|tremor|involuntary movement|incoordination|numbness|feeling of pins and needles or tingles"] Hematologic: [checklist name="Heme" value="anemia|easy bruising|easy bleeding|past transfusions"] Endocrine: [checklist name="Endo" value="abnormal growth|increased thirst|increased urine production|thyroid issues|heat/cold intolerance|excessive sweating|diabetes"] Psychiatric: [checklist name="Psych" value="anxiety|muscle tension|depression|thoughts of suicide|self harm|thoughts of hurting others|memory issues|sleep issues|change in mood|pleasure in doing things|ADD/ADHD|past treatment with psychiatrist|other psychiatric diagnosis"] OBJECTIVE Vital Signs: [textarea cols=80 rows=1 default="HR: T: P: SPO2: R: BP: HT: WT: "] PHYSICAL EXAM General: [textarea name="variable_21" default="Insert abnormalities or delete this text to remove."] [checkbox name="GeneralPE" value="A&Ox4. |Does not appear to be in any acute distress. |Well-groomed. |Appears stated age."] Neuro: [textarea name="variable_22" default="Insert abnormalities or delete this text to remove."] [checkbox name="NeuroPE" value="Normal motor function w/ muscle strength 5/5 b/l on UE and LE. |Sensation is intact b/l. |Memory is grossly intact. |Cerebral function and thought process intact. |No gait abnormalities observed. |Neuro exam not performed."] Integumentary: [textarea name="variable_23" default="Insert abnormalities or delete this text to remove."] [checkbox name="SkinPE" value="Skin is warm, dry, and intact.|No lesions.|No cyanosis or clubbing. |Integumentary exam not performed."] HEENT: [textarea name="variable_24" default="Insert abnormalities or delete this text to remove."] [checkbox name="HEENTPE" value="Head is normocephalic and atraumatic.|EOM intact. |PERRLA. |Hearing is grossly intact. |TM is normal in appearance|Nasal mucosa is pink and moist. |Oral mucosa is pink and moist w/ good dentition. |Pharynx is normal in appearance w/o tonsillar swelling or exudates. |Neck is supple w/o any lymphadenopathy. |Trachea is midline. |Thyroid gland is normal w/o any palpable masses. |Carotid pulse 2+ b/l w/o bruit. |No JVD.|"] Cardiopulmonary: [textarea name="variable_25" default="Insert abnormalities or delete this text to remove."] [checkbox name="CardpulmPE" value="Heart rate and rhythm are normal. |Normal S1 and S2. |No murmurs, gallops, rubs, or extra heart sounds. |Chest wall is symmetric and w/o deformity or signs of trauma. |No signs of respiratory distress. |Lungs CTA b/l w/o rales, ronchi, or wheezes. |Cardio exam not performed. |Pulmonary exam not performed."] GI: [checkbox name="GIPE" value="Abdomen is soft, symmetric, and non-tender w/o distention. |No visible lesions or scars. |Aorta is midline w/o bruit or visible pulsation.|Bowel sounds present in all four quadrants.|No masses, hepatomegaly, or splenomegaly are noted. |Abdominal exam not performed."][textarea name="variable_26" default="Insert abnormalities or delete this text to remove."] GU: [textarea name="variable_27" default="Insert abnormalities or delete this text to remove."] [checkbox name="GUPE" value=" No external masses or lesions. |Stool is normal in appearance.|External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. |Vagina is pink and moist w/o lesions or abnormal discharge. |Uterus is anteflexed, non-tender, and normal in size. |Ovaries are non-tender w/o palpable masses or enlargement. |Circumcised male. |Uncircumcised male. |Prepuce easily retracts. |No penile discharge or lesions. |No scrotal swelling or discoloration. |Testes descended b/l, smooth, no masses. |Epididymis nontender. |No inguinal or femoral hernias. |No GU exam performed. |No rectal exam performed."] Peripheral Vascular/MSK: [textarea name="variable_28" default="Insert abnormalities or delete this text to remove."] [checkbox name="PeriVascPE" value="UE and LE are atraumatic in appearance w/o tenderness or deformity. |No swelling or erythema. |Full ROM is noted in all joints. |Muscle strength is 5/5 b/l. |Tendon function is normal. |Cap refill is less than 3secs in all extremities. |Pulses palpable. |No peripheral vascular exam was performed. |No MSK exam was performed."] Psych: [textarea name="variable_29" default="Insert abnormalities or delete this text to remove."] [checkbox name="MSE" value="Appropriate mood and affect. |Adequate judgement and insight. |No visual or auditory hallucinations. |No SI or HI. |No parasuicidal thoughts or behavior. |MSE not performed."] ASSESSMENT [text name="variable_7" default="Problem Statement"] PLAN Diagnostics[checklist name="Diagnostics" value="xray|urinalysis|urine culture|vaginal swab|rapid Covid test|rapid flu test|rapid strep test|and|"] [checklist name="Pharmacotherapy" value="ampicillin|amoxicillin|amoxicillin with clavulanic acid|azithromycin|cefaclor |cefdinir|ceftriaxone|cefuroxime |cephalexin|ciprofloxacin|clarithromycin|clindamycin|dicloxacillin|doxycycline|levofloxacin|metrodnidazole|micocycline|nitrofurantoin|penicillin v potassium|prednisolone|sulfamethoxazole/trimethoprim 800/160|otic ciprofloxacin / dexamethasone |otic ciprofloxacin / fluocinolone|otic ofloxacin |otic hydrocortisone / neomycin / polymyxin b|(liquid) acetaminophen |(liquid) amoxicillin 400mg/5ml|(liquid) ibuprofen|(liquid) diphenhydramine ||||"] ** EDUCATION ** EDUCATION ** EDUCATION [textarea name="variable_8" default="Advised"] ** RESOURCES ** RESOURCES ** RESOURCES ** [link url="https://www.typhongroup.net/nsst/data/login.asp" memo="Typhon 3257/9022025953/CPR12#$"] [link url="https://vle.phoenix.edu/ultra/course" memo="UOP Blackboard"] [link url="https://fpnotebook.com/" memo="FP Book"] [link url="https://www.epocrates.com/login?refernext=https://www.epocrates.com/account/profile" memo="Epocrates ALNRN/CPR5"] [link url="https://next.amboss.com/us" memo="Amboss asripors/cy714"]
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Sandbox Metrics: Structured Data Index 0.71, 61 form elements, 64 boilerplate words, 4 text boxes, 12 text areas, 1 dates, 12 checkboxes, 24 check lists, 1 radio buttons, 2 drop downs, 5 links, 287 total clicks
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