Miscellaneous
Loading Add to Favorites
0 ratings, 0 votes0 ratings, 0 votes (0 rating, 0 votes, rated)
You need to be a registered member to rate this.
Loading...
Share
Tweet
Cite
GENERAL: [checkbox name="variable_1" value="Well appearing|Ill appearing|Tired appearing| Uncomfortable appearing|Unconscious|Elderly| Caucasian| African American | Hispanic | Asian| Male|Female |Comfortable and conversational| Alert and Oriented x 3.| Only oriented to XXX."] [text name="variable_1" default=""]

HEENT
[checkbox name="variable_2" value="HEAD |No maxillary or frontal sinus tenderness to palpation. No periauricular lymphadenopathy.
"]

[checkbox name="variable_3" value="EYES:"] [checkbox name="variable_4" value="Pupils equal and reactive to light bilaterally| Extra-ocular movements intact|No conjunctival pallor. | Conjunctiva w/pallor."]

[checkbox name="variable_5" value="EARS:"] [checkbox name="variable_6" value="Otoscopic exam of R and L ear. Bilateral ears with normal internal anatomy, no erythema, drainage, fluid, or foreign body. TM intact bilaterally w/positive light reflex. Hearing grossly intact.| Cerumen present. "]

[checkbox name="variable_7" value="NOSE:"] [checkbox name="variable_8" value="Patent nares w/no rhinorrea, discharge. Nasal turbinates w/no erythema.
"]
[checkbox name="variable_9" value="ORAL CAVITY:"] [checkbox name="variable_10" value="Moist oral mucosa w/no lesions, erythema or exudates. Normal dentition.|Moist oral mucosa w/no lesions, erythema or exudates. Poor dentition. |No sublingual jaundice.| OSA- Poor visualization of the posterior oropharynx due to excess tissue."]

[checkbox name="variable_11" value="NECK:"] [checkbox name="variable_12" value="Non-tender, no palpable cervical or supraclavicular lymphadenopathy."] [checkbox name="variable_12" value="No thyromegaly."]

CARDIAC: [checkbox name="variable_14" value="Audible S1 and S2. Regular Rate and Rhythm.|Audible S1 and S2. Tachycardia measured at XXX BPM. "] [checkbox name="variable_15" value="No murmurs, rubs, or gallops.| No JVD|Murmur- X/6 best heard at the X"]

PULMONARY: [checkbox name="variable_16" value="Clear to auscultation bilaterally. Non-labored respiration.|Wheezing appreciated | Crackles appreciated"]

[checkbox name="variable_17" value="ABDOMINAL:"] [checkbox name="variable_18" value="Soft, nontender, nondistended. No guarding or rebound. No masses palpated. | Soft, TTP in the XXX quadrant. No guarding or rebound. No masses palpated. | Costovertebral angle tenderness present on right flank| Costovertebral angle tenderness present on left flank| No costovertebral angle tenderness."]

[checkbox name="variable_19" value="Upper extremities:"]
[checkbox name="variable_20 value="option A|option B|option C"]

[checkbox name="variable_21" value="EXTREMITIES-Lower:"]

[checkbox name="variable_22" value="
No LE edema bilaterally. 2+ PT/DP Pulses|1+ pitting LE edema bilaterally up to XX|2+ pitting LE edema bilaterally up to XX"|Improved from previous exam |Worsened from previous exam]

[checkbox name="variable_23" value="Diabetic Foot Exam:"]

-Hair is [select name="variable_1" value="present on bilateral lower extremities and feet.|sharply demarcated lack of hair beginning at the| sparse hair present on lower legs and feet."]
-Dorsalis Pedis pulse is [select name="variable_2" value="present|absent|weak"] bilaterally.
-Posterior tibial pulse is [select name="variable_3" value="present|absent|weak"] bilaterally.
-Skin is [select name="variable_4" value="warm|cold"] to touch.
- [select name="variable_5" value="NO wounds are present on bilateral feet or digits.| Wounds PRESENT:"] There is no dryness or cracking in between the toes bilaterally.
-Nails are [select name="variable_6" value="well-kempt, with good hygiene.|Unkempt."]
-Right monofilament: /5
-Left monofilament: /5



[checkbox name="variable_24" value="SKIN:"]



[checkbox name="variable_25" value="NEURO EXAM:"]

[checkbox name="variable_26" value="GU:"]

[checkbox name="variable_27" value="Normal penis w/no lesions, erythema, crusting. Bilateral testis. No inguinal hernia.| -Mass palpated superior to L testis w/consistency of "bag of worms""]

Breasts: Normal, no masses, no skin changes, no discharge.

Woman w/all pelvic organs
External Genitalia: Normal female without lesions.
Vagina: normal, no abnormal discharge.
Cervix: no lesions, no cervical motion tenderness, no discharge
Bimanual: Uterus not enlarged, mobile, nontender, no adnexal masses


Woman s/p total hysterectomy, removal of tubes and ovaries
Cervix: absent
Bimanual: Uterus and ovaries absent

Woman s/p supracervical hysterectomy
Cervix: no lesions, no cervical motion tenderness, no discharge
Bimanual: Uterus and ovaries absent
Woman s/p total hysterectomy, ovaries and tubes remain
Cervix: absent
Bimanual: Uterus absent, no adnexal masses
GENERAL:

HEENT











CARDIAC:

PULMONARY:












-Hair is
-Dorsalis Pedis pulse is bilaterally.
-Posterior tibial pulse is bilaterally.
-Skin is to touch.
- There is no dryness or cracking in between the toes bilaterally.
-Nails are
-Right monofilament: /5
-Left monofilament: /5













Breasts: Normal, no masses, no skin changes, no discharge.

Woman w/all pelvic organs
External Genitalia: Normal female without lesions.
Vagina: normal, no abnormal discharge.
Cervix: no lesions, no cervical motion tenderness, no discharge
Bimanual: Uterus not enlarged, mobile, nontender, no adnexal masses


Woman s/p total hysterectomy, removal of tubes and ovaries
Cervix: absent
Bimanual: Uterus and ovaries absent

Woman s/p supracervical hysterectomy
Cervix: no lesions, no cervical motion tenderness, no discharge
Bimanual: Uterus and ovaries absent
Woman s/p total hysterectomy, ovaries and tubes remain
Cervix: absent
Bimanual: Uterus absent, no adnexal masses
Result - Copy and paste this output: