F42

Date of Visit
[date name="variable_1" default="00/00/20--"]

Age:[text name="Value_Generic" size="5"] Gender: [select name="variable_11" value="Female|Male"] Race:[select name="variable_12" value="Caucasian|Asian|Black|Hispanic|Native American|Other"]

HPI: 
[text name="variable_13" 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="Treatment details" cols="1" rows="4"]

Allergies:[checkbox name="Allergies: " value="NKDA|include"][text name= " variable_14" 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="Tetanus Vaccination" 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_30" 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_99" default="Advised"]
Date of Visit


Age: Gender: Race:

HPI:


Treatment

Allergies:
Medications: Supplements: Tetanus Vaccination
REVIEW OF SYSTEMS:
General:

Skin:

Head:

Eyes:

Ears:

Nose/Sinus:

Allergies:

Mouth/Throat:

Neck:

Breast:

Cardio:

Pulmonology:

GI:

Urinary:

Peripheral Vascular:

Musculoskeletal:

Neurologic

Hematologic:

Endocrine:

Psychiatric:

OBJECTIVE
Vital Signs:
PHYSICAL EXAM
General:


Neuro:


Integumentary:


HEENT:


Cardiopulmonary:


GI:


GU:


Peripheral Vascular/MSK:


Psych:

ASSESSMENT



PLAN
Diagnostics



** EDUCATION ** EDUCATION ** EDUCATION

Result - Copy and paste this output:

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