Transcriptionist SuperExport Format 1.0
{styles: [], class: '|template|, title: "Family History", author: "J Rick Adams, M.D.", labels: '|Palmedic|, text: "FAMILY HISTORY: <Family History picker>", appSym: '|Palmedic:JRAd|, need: TRUE, }

{styles: [], class: '|template|, need: TRUE, title: "History of Present Illness", author: "J. Rick Adams, M.D.", viewState: '|styled|, labels: '|Palmedic|, text: "HISTORY OF PRESENT ILLNESS: {First} {Last} is a {Patient description} with <PMH picker>. {S/He} presented with chief complaint of {Chief complaint}.
<ROS picker>", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "Physical Exam", author: "J Rick Adams, M.D.", labels: '|Palmedic|, text: "PHYSICAL EXAM: <Physical Exam picker>", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "Review of Systems", author: "J Rick Adams, M.D.", labels: '|Palmedic|, text: "REVIEW OF SYSTEMS: <ROS picker>", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "Social History", author: "J Rick Adams, M.D.", labels: '|Palmedic|, text: "SOCIAL HISTORY: <Social History picker>", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (complete)", author: "J Rick Adams", viewState: '|styled|, labels: '|_all|, text: "General: <ROS (general)>
Skin: <ROS (skin)>
ENT: <ROS (ENT)>
Pulmonary: <ROS (pulmonary)>
CV: <ROS (cardiac)>
GI: <ROS (GI)>
GU: <ROS (GU)>
Hematologic: <ROS (hematologic)>
Neuro: <ROS (neuro)>
Endocrine: <ROS (endocrine)>
Musculoskeletal: <ROS (musculoskeletal)>", appSym: NIL, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (chest pain)", author: "John R. Adams", viewState: '|styled|, labels: NIL, text: "<symbol:(-)> nausea, <symbol:(-)> diaphoresis", }

{styles: [], class: '|template|, need: TRUE, title: "ROS (CHF)", author: "J Rick Adams", viewState: '|styled|, labels: '|_all|, text: "<symbol:(-)> dyspnea on exertion; <symbol:(-)> orthopnea; <symbol:(-)> paroxysmal nocturnal dyspnea; <symbol:(-)> peripheral edema", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (depression)", author: "J Rick Adams", viewState: '|styled|, labels: NIL, text: "<symbol:(-)> sleep disturbance; <symbol:(-)> suicidal ideation; <symbol:(-)> weight changes; <symbol:(-)> depressed affect; <symbol:(-)> decreased energy", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (diabetes)", author: "John R. Adams", viewState: '|styled|, labels: NIL, text: "<symbol:(-)> polydypsia , <symbol:(-)> polyuria, <symbol:(-)> polyphagia, <symbol:(-)> vision complaints, <symbol:(-)> peripheral neuropathy, <symbol:(-)> hyperventilation, <symbol:(-)> dehydration", }

{styles: [], class: '|template|, need: TRUE, title: "ROS (meningitis)", author: "J Rick Adams, M.D.", text: "<symbol:(-)> headache; <symbol:(-)> fever; <symbol:(-)> chills; <symbol:(-)> malaise; <symbol:(-)> vomiting; <symbol:(-)> mental status changes; <symbol:(-)> nuchal rigidity; <symbol:(-)> photophobia", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (HIV)", author: "J Rick Adams", viewState: '|styled|, labels: '|_all|, text: "<symbol:(-)> fever, <symbol:(-)> chills, <symbol:(-)> night sweats, <symbol:(-)> weight loss, <symbol:(-)> nausea, <symbol:(-)> vomiting, <symbol:(-)> headache, <symbol:(-)> scotoma, <symbol:(-)> diplopia, <symbol:(-)> dysphagia, <symbol:(-)> dyspnea, <symbol:(-)> cough, <symbol:(-)> diarrhea, <symbol:(-)> oral lesions, <symbol:(-)> adenopathy, <symbol:(-)> rash, <symbol:(-)> anorexia, <symbol:(-)> mental status change, <symbol:(-)> focal deficit, <symbol:(-)> seizure, <symbol:(-)> dysesthesia", }

{styles: [], class: '|template|, need: TRUE, title: "Physical Exam (complete)", author: "J Rick Adams", viewState: '|styled|, labels: NIL, text: "general: <physical exam (general)>
skin: <physical exam (skin)>
HEENT: <physical exam (HEENT)>
CV: <physical exam (CV)>
Iungs: <physical exam (lungs)>
abdomen: <physical exam (abdomen)>
extremities: <physical exam (extremities)> 
neuro: <physical exam (neuro)>
rectal: <physical exam (rectal)>", }

{styles: [], class: '|template|, need: TRUE, title: "Physical Exam (normal)", author: "John R. Adams", viewState: '|styled|, labels: NIL, text: "general: A&O x3
HEENT: NCAT, PERRLA, E0MI, sclera non-icteric, retina nL, ¿ papilladema, tympanic   membranes nL, mucosa pink and moist, neck supple with full ROM, ¿ lymphadenopathy, ¿ thyromegaly, trachea midline, car otid upstrokes 2+ bilaterally
CV: RRR without M/G/R
Lungs: CTA bilaterally
Abdomen: soft, NTND, normo-active bowel sounds, no masses, no HSM
Extremities: ¿ c/c/e, pulses 2+ throughout
Neuro: CN 2-12 grossly intact, strength 5/5 throughout, sensation intact, DTRs 2+/4 throughout", }

{styles: [], class: '|template|, need: TRUE, title: "physical exam (rash)", author: "J Rick Adams, M.D.", text: "a rash is located over the <location> |Anatomy|. It is characterized as <rash type>.", appSym: '|Palmedic:JRAd|, }

{class: '|macro|, multiple: TRUE, choices: ["PGF: |Diagnosis|","PGM: |Diagnosis|","MGF: |Diagnosis|","MGM: |Diagnosis|","Father: |Diagnosis|","Mother: |Diagnosis|","Sibling: |Diagnosis|","Child: |Diagnosis|",], title: "Family History picker", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: NIL, choices: ["no significant past medical history","a past medical history significant for |Diagnosis|","a past medical history significant for {PMH}","a past medical history significant for {Problems List}",], title: "PMH picker", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["[ROS (complete)]","[ROS (chest pain)]","[ROS (CHF)]","[ROS (depression)]","[ROS (diabetes)]","[ROS (meningitis)]","[ROS (HIV)]","cardiac: <ROS (cardiac)>","endocrine: <ROS (endocrine)>","ENT: <ROS (ENT)>","general: <ROS (general)>","GI: <ROS (GI)>","GU: <ROS (GU)>","hematologic: <ROS (hematologic)>","musculoskeletal: <ROS (musculoskeletal)>","neurologic: <ROS (neuro)>","pulmonary: <ROS (pulmonary)>","skin: <ROS (skin)>",], title: "ROS picker", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> palpitations","<symbol:(-)> hypertension","<symbol:(-)> murmur","<symbol:(-)> chest pain","<symbol:(-)> dyspnea","<symbol:(-)> orthopnea","<symbol:(-)> PND","<symbol:(-)> edema","<symbol:(-)> cyanosis","<symbol:(-)> ascites",], title: "ROS (cardiac)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> heat intolerance","<symbol:(-)> cold intolerance","<symbol:(-)> sweating","<symbol:(-)> thirst","<symbol:(-)> hunger","<symbol:(-)> increased urination","<symbol:(-)> goiter","<symbol:(-)> impotence","<symbol:(-)> hyperpigmentation",], title: "ROS (endocrine)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> congestion","<symbol:(-)> cough","described as <cough type>","<symbol:(-)> coryza","<symbol:(-)> deafness","<symbol:(-)> diplopia","<symbol:(-)> ear pain","<symbol:(-)> epistaxis","<symbol:(-)> eyes itching","<symbol:(-)> headache","<symbol:(-)> hoarseness","<symbol:(-)> lymphadenopathy","<symbol:(-)> neck stiffness","<symbol:(-)> photophobia","<symbol:(-)> rhinitis","<symbol:(-)> sinus pain","<symbol:(-)> sore throat","<symbol:(-)> syncope","<symbol:(-)> tinnitus","<symbol:(-)> tooth pain","<symbol:(-)> vertigo","<symbol:(-)> visual loss","<symbol:(-)> voice changes",], title: "ROS (ENT)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> weight change","<symbol:(-)> fever","<symbol:(-)> night sweats","<symbol:(-)> weakness","<symbol:(-)> fatigue",], title: "ROS (general)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> nausea","<symbol:(-)> vomiting","<symbol:(-)> dysphagia","<symbol:(-)> heartburn","<symbol:(-)> hematemesis","<symbol:(-)> change in bowel habits","<symbol:(-)> melena","<symbol:(-)> bright red blood per rectum","<symbol:(-)> constipation","<symbol:(-)> diarrhea","<symbol:(-)> abdominal pain","<symbol:(-)> gas","<symbol:(-)> jaundice","<symbol:(-)> hepatitis",], title: "ROS (GI)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> frequency","<symbol:(-)> urgency","<symbol:(-)> hesitancy","<symbol:(-)> nocturia","<symbol:(-)> dysuria","<symbol:(-)> hematuria","<symbol:(-)> incontinence","<symbol:(-)> infections","<symbol:(-)> stones","<symbol:(-)> menopause","last period |Number| <time units> ago","<symbol:(-)> discharge",], title: "ROS (GU)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> bruising","<symbol:(-)> bleeding","<symbol:(-)> anemia",], title: "ROS (hematologic)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> joint pain","<symbol:(-)> stiffness","<symbol:(-)> arthritis","<symbol:(-)> gout",], title: "ROS (musculoskeletal)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> fainting","<symbol:(-)> blackout","<symbol:(-)> seizure","<symbol:(-)> paralysis","<symbol:(-)> local weakness","<symbol:(-)> numbness","<symbol:(-)> tingling","<symbol:(-)> memory loss",], title: "ROS (neuro)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> cough","<symbol:(-)> sputum production","<symbol:(-)> hemoptysis","<symbol:(-)> wheezing","<symbol:(-)> asthma","<symbol:(-)> bronchitis","<symbol:(-)> emphysema","<symbol:(-)> pleurisy",], title: "ROS (pulmonary)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> rashes","<symbol:(-)> pruritis","<symbol:(-)> dry skin","<symbol:(-)> hair changes","<symbol:(-)> nail changes",], title: "ROS (skin)", labels: NIL, }

{class: '|macro|, choices: ["(+)","(-)","(?)","(n/a)","pending",], title: "symbol", labels: NIL, }

{class: '|macro|, choices: ["acute","chronic","non-productive","productive",], title: "cough type", labels: NIL, }

{class: '|macro|, choices: ["day(s)","hour(s)","minute(s)","month(s)","week(s)","year(s)",], title: "time units", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["[Physical Exam (complete)]","[Physical Exam (normal)]","{Physical Exam}","{Physical Exam (admission)}","vitals: {Vital signs}","vitals: BP: |Number|/|Number|; P: |Number|; R: |Number|; T: |Number|","general: <physical exam (general)>","skin: <physical exam (skin)>","HEENT: <physical exam (HEENT)>","CV: <physical exam (CV)>","lungs: <physical exam (lungs)>","abdomen: <physical exam (abdomen)>","extremities: <physical exam (extremities)>","neuro: <physical exam (neuro)>","nodes: <physical exam (nodes)>","pelvic: <physical exam (pelvic)>","rectal: <physical exam (rectal)>",], dynamicSort: NIL, title: "Physical Exam picker", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["alert and oriented x3","in no apparent distress","appropriate for age","pleasant","cooperative","non-responsive","responds only to pain","appears older than stated age",], title: "physical exam (general)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["no rashes","<symbol:(-)> jaundice","<symbol:(+)> skin tenting","<symbol:(+)> skin thickening","<symbol:(+)> telangectasias","<symbol:(+)> petechiae","[physical exam (rash)]",], title: "physical exam (skin)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["normal","PERRLA","EOMI","sclera anicteric","sclera icteric","retina normal","retina wIth fibrinous exudates","¿ lymphadenopathy","<symbol:(-)> thyromegaly","mucosa pink and moist","tonsilar exudates","pharynx erythematous","poor dentition","tympanic membranes normal","cerumen impaction","disc margins sharp",], dynamicSort: TRUE, title: "physical exam (HEENT)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["regular rate and rhythm","no murmurs, gallops or rubs","PMI non-displaced","I/VI systolic murmur","II/VI systolic murmur","heard best over base","heard best over apex","tachycardic","bradycardic","irregularly irregular","<symbol> JVD","<symbol> S4","distant",], title: "physical exam (CV)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["clear to auscultation and percussion bilaterally","coarse crackles in bilateral bases","coarse breath sounds throughout","decreased breath sounds","<symbol> wheezes","<symbol> crackles",], title: "physical exam (lungs)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["soft","non-tender","non-distended","obese","tense","distended","no hepatosplenomegaly","normoactive bowel sounds","hypoactive bowel sounds","hyperactive bowel sounds","abdominal girth of |Number| cm","liver span of |Number| cm","<symbol:(-)> palpable spleen","<severity> pain on palpation of  <location> quadrant","voluntary gaurding","involuntary gaurding","<symbol:(-)> fluid wave","<symbol:(-)> shifting dullness","<symbol:(-)> rebound",], title: "physical exam (abdomen)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["no clubbing","no cyanosis","no edema","dorsalis pedis pulse 2+","posterior tibial pulse 2+","capillary refill < 2 seconds","trace edema","1+ edema","2+ edema","3+ edema","4+ edema","no splinter hemorrhages",], title: "physical exam (extremities)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["CN II-XII grossly intact","no focal abnormalities","sensation WNL","strength WNL","strength |Number|<symbol>/|Number| <location>","reflexes WNL",], title: "physical exam (neuro)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["anterior cervical: <node description>","axillary: <node description>","epitrochlear: <node description>","femoral: <node description>","inguinal: <node description>","occipital: <node description>","postauricular: <node description>","posterior cervical: <node description>","preauricular: <node description>","submandibular: <node description>","submental: <node description>","supraclavicular: <node description>","tonsillar: <node description>",], dynamicSort: TRUE, title: "physical exam (nodes)", outlineFormat: TRUE, labels: '|_all|, }

{class: '|macro|, multiple: TRUE, choices: ["vaginal mucosa pink and moist","vaginal mucosa atrophic","cervix without lesions","cervix not present","no discharge","<symbol> cervical motion tenderness",], title: "physical exam (pelvic)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["normal sphincter tone","no masses palpated","guiaic <symbol>","no stool in vault",], title: "physical exam (rectal)", labels: NIL, }

{class: '|macro|, choices: ["mild","moderate","severe","better","worse","the same",], title: "severity", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["caudal","dorsal","left","lower","middle","right","third","upper","ventral",], dynamicSort: TRUE, title: "location", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["soft","firm","hard","mobile","fixed","tender","non-tender","|Number| cm in diameter",], title: "node description", labels: '|_all|, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> tobacco","<symbol:(-)> EtOH","<symbol:(-)> IVDA","(+) tobacco- |Number| pack(s) per day for |Number|  years","(+) tobacco- |Number| pack years","quit |Number| <time units:years> ago","(+) EtOH- |Number| drink(s) per <time units:day> for |Number|  years","quit |Number| <time units:years> ago",], title: "Social History picker", labels: NIL, }

{class: '|macro|, choices: ["absent","diffuse","erythematous","macular","maculo-papular","papular","petechial","well circumscribed",], title: "rash type", labels: NIL, }