WNL General Survey

[select name="variable_1" memo="<--- Select Exam" value="General Adult Exam|General Male Exam|General Female Exam"]
[var name="General:"][textarea name="variable_2" cols=80 rows=2 default="Awake, alert and oriented. No acute distress. Well developed, hydrated and nourished. Appears stated age."]
[var name="Head:"][textarea name="variable_3" cols=80 rows=1 default="The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed."]
[var name="Eyes:"][textarea name="variable_4" cols=80 rows=1 default="PERRLA, EOMI. Vision is grossly intact. Conjunctivae are clear without exudates or hemorrhage. Fundi appear normal including optic discs and vessels. No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions"]
[var name="Ears:"][textarea name="variable_5" cols=80 rows=1 default="The external ear and ear canal are non-tender and without swelling. The canal is clear without discharge. The tympanic membrane is normal in appearance with normal landmarks and cone of light. Hearing is intact with good acuity to whispered voice."]
[var name="Nose:"][textarea name="variable_6" cols=80 rows=1 default="Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally."]
[var name="Throat:"][textarea name="variable_7" cols=80 rows=2 default="Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]
[var name="Neck:"][textarea name="variable_8" cols=80 rows=1 default="Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[var name="Cardiac:"][textarea name="variable_9" cols=80 rows=3 default="Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 3 seconds. No carotid bruits."]
[var name="Lungs:"][textarea name="variable_10" cols=80 rows=2 default="The chest wall is symmetric and without deformity. No signs of trauma. Chest wall is non-tender. No signs of respiratory distress. Lung sounds are clear in all lobes bilaterally without rales, ronchi, or wheezes."]
[var name="Abdomen:"][textarea name="variable_11" cols=80 rows=2 default="Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[var name="Muskuloskeletal:"][textarea name="variable_12" cols=80 rows=2 default="Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[var name="Back"][textarea name="variable_13" cols=80 rows=2 default="Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm."]
[var name="Extremities:"][textarea name="variable_14" cols=80 rows=2 default="No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[var name="Lower Extremities:"][textarea name="variable_15" cols=80 rows=5 default="Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
[var name="Neurological:"][textarea name="variable_16" cols=80 rows=2 default="CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[var name="Skin:"][textarea name="variable_17" cols=80 rows=1 default="Skin normal color, texture and turgor with no lesions or eruptions."]
[var name="Psychiatric:"][textarea name="variable_18" cols=80 rows=3 default="The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."]
[conditional field="variable_1" condition="(variable_1).is('General Male Exam')"][var name="Rectal:"][textarea name="variable_19" cols=80 rows=2 default="Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular."][/conditional]
[conditional field="variable_1" condition="(variable_1).is('General Male Exam')"][var name="Genitalia:"][textarea name="variable_20" cols=80 rows=3 default="Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge."][/conditional][conditional field="variable_1" condition="(variable_1).is('General Female Exam')"][var name="Breasts:"][textarea name="variable_21" cols=80 rows=1 default="No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."][/conditional]
[conditional field="variable_1" condition="(variable_1).is('General Female Exam')"][var name="Pelvic:"][textarea name="variable_22" cols=80 rows=3 default="Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness."][/conditional]
<--- Select Exam













Lower Extremities:




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Sandbox Metrics: Structured Data Index 0.05, 47 form elements, 21 text areas, 1 drop downs, 21 variables, 4 conditionals, 22 total clicks
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