The Eloquent Physician - a Medical Record Software Program. Sample Doctor’s Chart Note

CHIEF COMPLAINT / HPI: (fullName), a (age) year old (sex) patient, presents today complaining of {a sudden onset of | a gradual onset of | chronic persistent | chronic intermittent} {chest pain | epigastric pain | visceral pain | {RIGHT LEFT or BILATERAL} arm pain | neck pain | jaw pain | chest tightness | chest heaviness | chest pressure or squeezing | crushing | dyspnea | diaphoresis | weakness | nausea | vomiting | numbness or tingling | palpitations | fainting | dizziness | vague discomfort}. These symptoms began approximately {1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 18 | 20 | 22 | 24 | 25 | 30 | 35 | 40 | 45 | 50 | 55 | 60 | 65 | 70 | 75 | 80 | 85 | 90 | 95 | 96 | 97 | 98 | 99 | 100 | 101 | 102 | 103 | 104 | 105 | 106 | 110 | 115 | 120 | 125 | 130 | 140 | 150 | 160 | 170 | 180 | 190 | 200 | >200} {year | years | month | months | week | weeks | day | days | hour | hours | minute | minutes | second | seconds} ago {while at rest | while asleep | during normal physical activity | after normal physical activity | during strenuous physical activity | after strenuous physical activity | while eating | after eating | after trauma | after a stressful event | at random times of the day | after using tobacco | after using cocaine}. (His_Her) dominant symptom is described as {a sharp | a dull | a stabbing | a tearing | an aching | a crampy | a burning | a prolonged} {{PAIN_PRESSURE_ETC} which radiates to {CARDIAC PAIN RADIATION} | {PAIN_PRESSURE_ETC} which does not radiate to any other area}. The primary location of discomfort is {in the right chest | in the left chest | in the mid-chest | located sub-sternally | located retro-sternally | in the epigastrum | in the right upper abdomen | in the right lower abdomen | in the left upper abdomen | in the left lower abdomen | throughout the abdomen | in the left mid-scapula | in the right mid-scapula}. On a scale of one to ten with ten being the most intense sensation ever experienced and one being the least, (he_she) describes the intensity of these symptoms as "{ten out of ten | nine out of ten | eight out of ten | seven out of ten | six out of ten | five out of ten | four out of ten | three out of ten | two out of ten | one out of ten}." The symptoms {CHANGED chest pain | epigastric pain | visceral pain | {RIGHT LEFT or BILATERAL} arm pain | neck pain | jaw pain | chest tightness | chest heaviness | chest pressure or squeezing | crushing | dyspnea | diaphoresis | weakness | nausea | vomiting | numbness or tingling | palpitations | fainting | dizziness | vague discomfort}. This is {the first experience | the second experience in {ELAPSED TIME Number} {ELAPSED TIME Interval} | the third experience in {ELAPSED TIME Number} {ELAPSED TIME Interval} | the fourth experience in {ELAPSED TIME Number} {ELAPSED TIME Interval} | the fifth experience in {ELAPSED TIME Number} {ELAPSED TIME Interval} | the most recent of several experiences in the last {ELAPSED TIME Number} {ELAPSED TIME Interval}} (he_she) has had with this problem. (firstName) {made no attempt to alleviate symptoms at home | initially waited approximately {NUMBER 1 - 25} {ELAPSED TIME Interval} for the symptoms to abate | took {NUMBER 1 - 25} aspirin before seeking help | took {NUMBER 1 - 25} antacid tablets before seeking help | took {NUMBER 1 - 25} sub-lingual nitro glycerin before seeking help}. (He_She) {came immediately to this office for evaluation | eventually decided to come to this office for evaluation | was evaluated by ambulance personnel but not treated before coming to this office | was evaluated by ambulance personnel, treated with {TREATMENT EMS} then {FACILITY}}. CARDIAC HISTORY: (firstName) {has no significant prior cardiac history | has a positive cardiac history which is significant for {CARDIAC HISTORY} | has an unknown cardiac history | has some prior cardiac history, the details of which are uncertain}. (His_Her) cardiac risk profile is significant for {no known cardiac risk factors | no cardiac risk factors in addition to this history | being of the advanced age of {AGE} | having {FAMILY MEMBER} who suffered an MI at the age of {AGE} | currently smoking with an accumulated {PACK-YEAR-HISTORY} pack-year history | having quit smoking {NUMBER OF YEARS} ago after accumulating a {PACK-YEAR-HISTORY} pack-year history | morbid obesity | hypertension | hypercholesterolemia | diabetes mellitus | being a male | current cocaine use | a history of cocaine use. The last time was {ELAPSED TIME Number} {ELAPSED TIME Interval} ago}. CURRENT MEDICATIONS: {Vicodin | Oxycontin | Percodan | Percocet | Lortab | Lorcet | Vicodin ES | Darvocet N100 | Skelaxin | Zanaflex | Celebrex | Vioxx | Voltaren | Anti-biotics | Anti-Hypertensive medication | Cholesterol Medication | Pepsid | Neurontin | Elavil | None | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Arthrotec | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} ALLERGIES: { | | | | No Known Drug Allergies | Aspirin results in {ALLERGIC REACTION} | Penicillin results in {ALLERGIC REACTION} | Sulfa Drugs result in {ALLERGIC REACTION} | {LIST MEDICATIONS} results in {ALLERGIC REACTION} | | {ALLERGIES MEDICATIONS} | {ALLERGIES FOOD} | {ALLERGIES ENVIRONMENT} | | None | Aspirin | Penicillin | Sulfa drugs | | Bees - wasps | Hay fever | Pineapple | Strawberries} Negative | Positive, as described in the history above | Positive for the following systems; {MEDICAL SYSTEMS}: {Negative | Positive, as described in the history above | Positive for the following systems; {MEDICAL SYSTEMS}}. Appendectomy | Cardiac Bypass | Cataract removal | Colonoscopy | Cosmetic surgery | Gall bladder removal | Rhinoplasty | Tonsillectomy | Tracheotomy | Arterial shunt | Cardiac nodal ablation | Pacemaker insertion | PIC line placement | Porta cath placement | Breast reconstruction | Breast enlargement | Heart valve replacement | Indwelling defibrillator | Laparoscopy | Splenectomy | Whipple's procedure | Hernia repair | Liver biopsy | Nephrectomy | Repair of AAA | Stomach stapling | Hysterectomy | Salpingectomy | Vasectomy | Colon resection | C-section | Tubal ligation | Negative | Appendectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac Bypass {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cataract removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colonoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cosmetic surgery {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Gall bladder removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Rhinoplasty {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tonsillectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tracheotomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Arterial shunt{ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac nodal ablation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Pacemaker insertion {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | PIC line placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Porta cath placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast reconstruction {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast enlargement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Heart valve replacement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Indwelling defibrillator {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Laparoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Splenectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Whipple's procedure {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hernia repair {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Liver biopsy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Nephrectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Repair of AAA {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Stomach stapling {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hysterectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Salpingectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Vasectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colon resection {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | C-section {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tubal ligation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | A-V fistula for dialysis: {Appendectomy | Cardiac Bypass | Cataract removal | Colonoscopy | Cosmetic surgery | Gall bladder removal | Rhinoplasty | Tonsillectomy | Tracheotomy | Arterial shunt | Cardiac nodal ablation | Pacemaker insertion | PIC line placement | Porta cath placement | Breast reconstruction | Breast enlargement | Heart valve replacement | Indwelling defibrillator | Laparoscopy | Splenectomy | Whipple's procedure | Hernia repair | Liver biopsy | Nephrectomy | Repair of AAA | Stomach stapling | Hysterectomy | Salpingectomy | Vasectomy | Colon resection | C-section | Tubal ligation | Negative | Appendectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac Bypass {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cataract removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colonoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cosmetic surgery {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Gall bladder removal {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Rhinoplasty {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tonsillectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tracheotomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Arterial shunt{ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Cardiac nodal ablation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Pacemaker insertion {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | PIC line placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Porta cath placement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast reconstruction {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Breast enlargement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Heart valve replacement {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Indwelling defibrillator {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Laparoscopy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Splenectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Whipple's procedure {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hernia repair {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Liver biopsy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Nephrectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Repair of AAA {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Stomach stapling {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Hysterectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Salpingectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Vasectomy {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Colon resection {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | C-section {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | Tubal ligation {ELAPSED TIME Number} {ELAPSED TIME Interval} ago | A-V fistula for dialysis}. OBJECTIVE EVALUATION: Upon initial observation, (firstName) appeared to be {a well nourished and generally healthy | a well nourished but generally ill | a thin but well nourished and generally healthy | a thin, well nourished but generally ill | a heavy but generally healthy | a heavy and generally ill | an obese but generally healthy | an obese and generally ill} (age) year old {Oriental | | Caucasian | Black | Hispanic | Asian | Indian | American Indian} (SEX), {in no obvious distress | in severe respiratory distress | having some respiratory difficulty | in obvious physical pain | having difficulty getting comfortable | in an agitated state | worried looking} with {normal skin tone | a "shocky" appearance and pale looking skin | a "shocky" appearance and ashen looking skin | a "shocky" appearance and cyanotic looking skin}. (He_She) was {alert and fully oriented to person place and thing | alert and oriented to person and place only | alert and oriented to person only | alert but disoriented to person, place and time | neither alert nor oriented}, {standing comfortably in the exam room | standing uncomfortably in the exam room | pacing the exam room, in great discomfort | seated in a chair, resting comfortably | seated on a chair uneasily | seated on a chair, in great discomfort | seated on the exam bed, resting comfortably | seated on the exam bed, uneasily | seated on the exam bed in great discomfort | lying semi-reclined on the exam bed, resting comfortably | lying semi-reclined on the exam bed, uneasily | lying semi-reclined on the exam bed in great discomfort | lying supine on the exam bed, resting comfortably | lying supine on the exam bed, restlessly | lying supine on the exam bed in great discomfort | sleeping quietly on the exam bed | lying unconscious on the exam bed}. (firstName) {responded easily to questions and provided a detailed history | responded easily to questions but provided a poorly detailed history | responded with difficulty to questions, secondary to discomfort, but provided a detailed history | responded with difficulty to questions, secondary to discomfort, and provided a poorly detailed history | was unable to respond to questions, secondary to discomfort}.