Acute Adult Physical Exams

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[select name="Q1" value="Allergic Rhinitis|Bronchitis|Conjunctivitis|Dizziness|Gastroenteritis|Migraine/Headache|Otitis|Pharyngitis|Shortness of Breath|Stye|Urinary Tract Infection"][conditional field="Q1" condition="(Q1).is('Allergic Rhinitis')"]
[text size=112 default="General Appearance: alert, NAD."]
[text size=112 default="Nose: normal, mucosa without edema or inflammation. No clear or purulent nasal discharge."]
[text size=112 default="Ears: TMs bilaterally intact, without bulging or erythema."]
[text size=112 default="Eyes: normal conjunctiva, lids, PERRL"]
[text size=112 default="Throat: normal, without erythema, tonsillar inflammation or exudate. No posterior pharyngeal drainage"]
[text size=112 default="Lungs: clear to ausculation bilaterally. No wheezes or crackles."]
[text size=112 default="Heart: RR; no murmur/click, S3/S4"][/conditional][conditional field="Q1" condition="(Q1).is('Pharyngitis')"]
[text size=112 default="GEN: Alert, well nourished and well hydrated, in no distress."]
[text size=112 default="HEENT: Conjunctiva normal."]
[text size=112 default="Auditory canals normal."]
[text size=112 default="Right tympanic membrane is intact without fluid or erythema."]
[text size=112 default="Left tympanic membrane: is intact without fluid or erythema."]
[text size=112 default="Nares without clear or mucopurulent rhinorrhea bilaterally."]
[text size=112 default="Oral exam without lesions, posterior pharynx without erythema or tonsillar exudates; no palatal petechiae."]
[text size=112 default="NECK: Supple, tender adenopathy anteriorly; no posterior nodes palpable."]
[text size=112 default="LUNGS: Clear to auscultation without wheezes, rales, or rhonchi. Good excursions. No dullness on percussion."]
[text size=112 default="COR: RRR with normal S1, S2 without murmur, gallop, or rub."]
[text size=112 default="ABD: Soft, non-tender, without hepatosplenomegaly"]
[text size=112 default="SKIN: No rash present"][/conditional][conditional field="Q1" condition="(Q1).is('Conjunctivitis')"]
[text size=112 default="General Appearance: NAD"]
[text size=112 default="Visual acuity: Normal, Snellen results as recorded by nurse"]
[textarea default="Left eye exam: normal, PERRL, extraocular movements normal. Conjunctiva without injection. Mattering and excessive tearing is absent. No visible corneal abrasion or foreign body. Eyelids normal. Fundus normal."]
[textarea default="Right eye exam: normal, PERRL, extraocular movements normal. Conjunctiva without injection. Mattering and excessive tearing is absent. No visible corneal abrasion or foreign body. Eyelids normal. Fundus normal."]
[text size=112 default="Fluorescein exam of affected eye is normal, without corneal abrasion."][/conditional][conditional field="Q1" condition="(Q1).is('Stye')"]
[text size=112 default="General Appearance: NAD"]
[text size=112 default="Eyes: visual acuity as recorded by nurse, pupils equal and reactive, EOMI, funduscopic exam normal, corneas normal, conjunctiva normal without injection."]
[text size=112 default="Left eyelid without erythema or swelling. no visible pustule or mass. No drainage. "]
[text size=112 default="Right eyelid without erythema or swelling. no visible pustule or mass. No drainage."]
[text size=112 default="There is no periorbital swelling."]
[text size=112 default="Ears: normal TMs bilaterally."]
[text size=112 default="Lymph nodes: normal. no anterior or posterior cervical adenopathy."][/conditional][conditional field="Q1" condition="(Q1).is('Otitis')"]
[text size=112 default="General: Patient is alert and in no distress."]
[text size=112 default="Head: Normocephalic."]
[text size=112 default="ENT: External examination of the nose is normal."]
[text size=112 default="External examination of the ears is normal."]
[text size=112 default="Internal examination of the nose without congestion."]
[text size=112 default="Right tympanic membrane is intact without fluid or erythema."]
[text size=112 default="Left tympanic membrane is intact without fluid or erythema."]
[text size=112 default="Throat: Without tonsillar hypertrophy or exudate. No erythema at posterior pharynx. "]
[text size=112 default="Neck: Supple, negative Kernig and Brudzinski"]
[text size=112 default="Heart: RR, no murmur/click."]
[text size=112 default="Lungs: Clear to auscultation and percussion, without rhonchi or wheezes."][/conditional][conditional field="Q1" condition="(Q1).is('Dizziness')"]
[text size=112 default="General Appearance: No distress."]
[text size=112 default="EENT: PERRL, fundi normal, ears normal."]
[text size=112 default="Positional testing for nystagmus do not elicit subjective symptoms or vertigo or nystagmus."]
[text size=112 default="Heart: RR, no murmur/click, S3/S4"]
[text size=112 default="Lungs: clear to auscultation bilaterally."]
[text size=112 default="Neuro: symmetric DTR's, strength intact/symmetric, Babinski sign is absent, finger to nose is normal, tandem walking is normal."]
[text size=112 default="Cranial nerves 2-12 are normal."][/conditional][conditional field="Q1" condition="(Q1).is('Migraine/Headache')"]
[text size=112 default="General Appearance: alert, NAD. Photophobia is not apparent."]
[text size=112 default="Eyes: PERRL, fundi normal, EOMI"]
[text size=112 default="HENT: ears normal, pharynx normal."]
[text size=112 default="Neck: supple"]
[text size=112 default="Heart: RR, normal S1 and S2, no murmur"]
[text size=112 default="Lungs: clear to auscultation bilaterally."]
[text size=112 default="Neuro: Cranial nerves: 2-12 intact. "]
[text size=112 default="Reflexes: normal, symmetric at upper and lower extremities. Babinski sign absent."]
[text size=112 default="Strength: normal, symmetric at upper and lower extremities."]
[text size=112 default="Cerebellar function tests: Romberg normal, finger to nose normal, tandem walking normal."][/conditional][conditional field="Q1" condition="(Q1).is('Bronchitis')"]
[text size=112 default="General: Patient is alert and in no acute distress."]
[text size=112 default="ENT: No tonsillar hypertrophy or exudate. No erythema at posterior pharynx. External examination of the ears and nose is normal."]
[text size=112 default="Right tympanic membrane is intact without fluid or erythema."]
[text size=112 default="Left tympanic membrane: is intact without fluid or erythema."]
[text size=112 default="Lymph Nodes: no anterior cervical adenopathy. no posterior cervical adenopathy."]
[text size=112 default="Heart: RR; no murmur/click, S3/S4"]
[text size=112 default="Lungs: clear to auscultation and percussion bilaterally, no rhonchi or wheezes."]
[text size=112 default="Chest x-ray: negative for focal infiltrate, no bronchial inflammation, no bilateral perihilar infiltrates"][/conditional][conditional field="Q1" condition="(Q1).is('Shortness of Breath')"]
[text size=112 default="General Appearance: No acute distress. Patient has no apparent cyanosis."]
[text size=112 default="Nose: without nasal discharge."]
[text size=112 default="Ears: normal bilaterally, bilateral TMs intact without bulging or erythema"]
[text size=112 default="Throat: without tonsillar swelling or exudate."]
[text size=112 default="Lymph nodes: without anterior cervical, posterior cervical, or supraclavicular adenopathy."]
[text size=112 default="Heart: normal heart sounds no murmur, no JVD"]
[text size=112 default="Lungs: normal, good air movement bilaterally, no wheezing, rhonchi, or rales."]
[text size=112 default="Lower extremities: normal, without pitting edema."]
[text size=112 default="Pulse oximetry: normal"]
[text size=112 default="Chest x-ray: normal, without infiltrates."][/conditional][conditional field="Q1" condition="(Q1).is('Gastroenteritis')"]
[text size=112 default="General Appearance: NAD."]
[text size=112 default="Skin: adequate turgor"]
[text size=112 default="Ears: normal."]
[text size=112 default="Mouth: mucosa moist. pharynx is without erythema or tonsillar hypertrophy."]
[text size=112 default="Heart: normal heart sounds, no murmur"]
[text size=112 default="Lung: clear without rhonchi or wheezes"]
[text size=112 default="Abdomen: no mass, no tenderness nor organomegaly. bowel sounds are present"][/conditional][conditional field="Q1" condition="(Q1).is('Urinary Tract Infection')"]
[text size=112 default="General Appearance: well hydrated, alert, in no acute distress."]
[text size=112 default="BACK: no CVAT"]
[text size=112 default="ABDOMEN: Soft, tender over the suprapubic area without masses or hepatosplenomegaly. Not distended."]
[text size=112 default="Pelvis: normal, without perineal erythema, vaginal discharge, or adnexal abnormality. no cervical motion tenderness."]
[text size=112 default="Dip UA shows no nitrite, leukocytes, or protein."]





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