Adult PE

DOS:[date name="DOS" default=""]
Name:[text name="Name" default=""]


REVIEW OF SYSTEMS:
General:
[checklist name="General" value="fever|chills|fatigue|appetite changes|weight change"]
Head:[checklist name="Head" value="headaches|head injury"] 
Eyes:[checklist name="Eyes" value="vision changes|visual disturbances|corrective lenses"]
Ears:[checklist name="Ears" value="ear pain|discharge|ringing|dizziness"]
Nose/Sinus:[checklist name="NoseSinus" value="nose bleeds|congestion|discharge"]
Cardio:[checklist name="Cardio" value="chest pain|palpitations|heart murmur|change in color of fingers or toes|swelling in hands or feet"]
Pulmonology:[checklist name="Pulm" value="shortness of breath|cough|production of phlegm|hemoptysis"]
GI:[checklist name="GI" value="problems swallowing|heartburn|nausea|vomiting|diarrhea|constipation|change in bowel habits|abdominal pain|rectal bleeding|yellowing of skin"]
Urinary:[checklist name="Urinary" value="difficulty in urination|pain or burning with urination|frequent urination at night|urgent need to urinate|incontinence of urine|dribbling|decreased urine stream|blood in urine"]
Msk:[checklist name="MSK_list" value="joint pain|back pain|muscle problems|swelling|stiffness|decreased ROM|difficulty walking"]
Skin:[checklist name="Skin" value="rashes|other skin complaints"]
Peripheral Vascular:
[checklist name="PeripheralVascular" value="leg cramps|varicose veins|clots in veins|venous stasis"]
Neuro: [checklist name="Neuro_list" value="HA|migraines|seizures|LOC/fainting|paralysis|weakness|muscle spasms|tremor|numbness|tingling|involuntary movement|incoordination|memory deficits"]
Endocrine:[checklist name="Endo" value="increased thirst|increased urine production|heat/cold intolerance|excessive sweating"]
Immunologic: [checklist name="imm" value="TB|hepatitis|recurrent infections"]
Hematologic:[checklist name="hemm" value="anemia|easy bleeding"]
Psychiatric:[checklist name="Psych" value="anxiety|muscle tension|depression|SI|self harm|thoughts of hurting others|memory issues|sleep issues|change in mood|pleasure in doing things"]


Objective

Vital Signs
Temp [text name="temp" default=""]F BP[text name="BP" default=""] HR [text name="HR" default=""] RR [text name="RR" default=""] SpO2 [text name="variable_1" default=""]%


Physical Exam
General: 
[textarea name="general" default=""] 
[checkbox name="GeneralPE" value="A&Ox4.|A&Ox3. |A&Ox2.|A&Ox1. |Anxious. |Tearful. |Lethargic. |Alert. |Does not appear to be in any acute distress. |Well nourished. |Obese. |Thin. |Frail. |Unkept. |Well-groomed. |Appears stated age. |Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]

Neuro: 
[textarea name="variable_22" default=""] 
[checkbox name="NeuroPE" value="Normal motor function w/ muscle strength 5/5 b/l on UE and LE. |Sensation is intact b/l. |Sensation is decreased in BLE. |Sensation is decreased b/l feet. |Memory is grossly intact. |Cerebral function and thought process intact. |No gait abnormalities observed. |Neuro exam not performed. |CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]

Head:[textarea name="head_text" default=""] 
[checklist name="head" value="Head is normocephalic and atraumatic. |Head is w/o tenderness, visible or palpable masses, and depressions. |Hair is of normal texture and distribution."]

Eyes: [textarea name="eyes_text" default=""]
[checklist name="eyes" value="Conjunctiva are clear w/o excudates or hemorrhage. |Sclera is non-icteric. |EOM intact. |PERRLA. | PERRLA, EOMI. Fundus normal, vision is grossly intact."]

Ears:[textarea name="ears_text" default=""]
[checklist name="ears" value="Bilateral external ear canals are non-tender and w/o swelling. |Hearing is grossly intact. |Difficulty hearing. |Hearing aide present. |TM is normal in appearance w/ normal landmarks and cone of light. |External auditory canals and tympanic membranes clear, hearing grossly intact."]

Nose:[textarea name="nose_text" default=""] 
[checklist name="nose" value="Clear nasal discharge. |Purulent nasal discharge. |No nasal discharge. |Nares patent b/l. |Nasal mucosa is pink and moist."]

Throat:[textarea name="variable_1" default="sample text"]
[checklist name="throat" value="Oral mucosa is pink and moist. |No inflammation, swelling, exudate, or lesions noted. |Good dentition. |Poor Dentation. |Dentures present. |Partials present. |Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]

Neck:[textarea name="neck_text" default=""]
[checklist name="neck" value="Supple, non-tender, w/o lymphadenopathy, masses or thyromegaly. |Trachea is midline. |Thyroid gland is normal w/o any palpable masses. |Carotid pulse 2+ b/l w/o bruit. |No JVD. |HEENT exam not performed. |Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]

Cardio: 
[textarea name="cardio_text" default=""] [checkbox name="CardpulmPE" value="Heart rate normal. |Tachycardia. |Bradycardia. |Regular rhythm. |Irregular rhythm. |Irregularly irregular rhythm. |Normal S1 and S2, no S3/S4. |S1/S2,S3 noted, no S4. |S1/S2, no S3, S4 noted. |S3 and S4 noted. |No murmurs, gallops, rubs, or extra heart sounds appreciated upon auscultation. |Chest wall is symmetric and w/o deformity or signs of trauma. |No edema noted. |Non-pitting BLE. |+1 pitting BLE. |+2 pitting BLE. |+3 pitting BLE. |Peripheral pulses are 2+ throughout. |Peripheral pulses are diminshed. |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 2 seconds. No carotid bruits."]

Respiratory: 
[textarea name="resp" default=""] [checkbox name="RespiratoryPE" value="No signs of respiratory distress. |Normal effort. |Labored breathing. |No increased work of breathing. |Tachypena. |Hypopena. |Rales/Rhonci. |Inspiratory wheezes b/l. |Expiratory wheezes b/l. |Inspiratory/Expiratory wheezes b/l. |Lungs CTA b/l w/o rales, ronchi, or wheezes. |Diminished breath sounds b/l. |Dyspena on exertion.  |Pulmonary exam not performed. |Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]

GI: 
[textarea name="variable_26" default=""] [checkbox name="GIPE" value="Abdomen is soft, symmetric, and non-tender w/o distention. |No visible lesions or scars. |Aorta is midline w/o bruit or visible pulsation. |Umbilicus is midline w/o herniation. |Normal BS in all four quadrants. |No masses, hepatomegaly, or splenomegaly are noted. |Abdominal exam not performed. |Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]

GU: 
[textarea name="variable_27" default=""] [checkbox name="GUPE" value=" Normal rectal sphincter tone. |No external masses or lesions. |Stool is normal in appearance. |External genitalia is normal in appearance w/o lesions, swelling, masses or tenderness. |Vagina is pink and moist w/o lesions or abnormal discharge. |Uterus is anteflexed, non-tender, and normal in size. |Ovaries are non-tender w/o palpable masses or enlargement. |Circumcised male. |Uncircumcised male. |Prepuce easily retracts. |No penile discharge or lesions. |No scrotal swelling or discoloration. |Testes descended b/l, smooth, no masses. |Epididymis nontender. |No inguinal or femoral hernias. |Exam deferred. "]
Integumentary: 
[textarea name="variable_23" default=""] [checkbox name="SkinPE" value="Skin is warm, dry, and intact.|No lesions.|Appropriate color for ethnicity. |Nail beds are pink. |No cyanosis or clubbing. |Clubbing of the fingers noted. |Integumentary exam not performed. |Skin normal color, texture and turgor with no lesions or eruptions."]

Musculoskeltal: 
[textarea name="variable_28" default=""] [checkbox name="PeriVascPE" value="Spine is in normal alignment. | Spine is kyphotic. | Lordosis curvature noted.| Scolosis noted. |UE and LE are atraumatic in appearance w/o tenderness or deformity. |No swelling or erythema. |Full ROM is noted in all joints. |Decreased ROM in UE.| Decreased ROM in LE.| Decreased ROM in all four extremites. |Contractures. |No contractures noted. |Curvature of the fingers noted - Mallet fingers. |Curvature of the fingers noted - Swan neck. | Curvature of the fingers - boutonniere deformity. |Muscle strength is 5/5 b/l. |Decreased muscle strength. |Gait independent. | Unsteady gait. | Utilizes cane or walker. |Utilizes wheelchair. | Non-ambulatory. |Cap refill is less than 3secs in all extremities. |Pulses palpable. |No peripheral vascular exam was performed. |No MSK exam was performed. |Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]

Psych: 
[textarea name="variable_29" default=""] [checkbox name="MSE" value="Appropriate mood and affect. |Pt is cooperative. |Conversant. |Confused. |Flat. |Distrustful. |Delusional. |Agitated.| Lethargic. |Unwilling to engage. |Adequate judgement and insight. |No visual or auditory hallucinations. |No SI or HI. |No suicidal thoughts or behavior. |MSE not performed."]
DOS:
Name:


REVIEW OF SYSTEMS:
General:

Head:
Eyes:
Ears:
Nose/Sinus:
Cardio:
Pulmonology:
GI:
Urinary:
Msk:
Skin:
Peripheral Vascular:

Neuro:
Endocrine:
Immunologic:
Hematologic:
Psychiatric:


Objective

Vital Signs
Temp F BP HR RR SpO2 %


Physical Exam
General:



Neuro:



Head:



Eyes:



Ears:



Nose:



Throat:



Neck:



Cardio:


Respiratory:


GI:


GU:

Integumentary:


Musculoskeltal:


Psych:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.61, 54 form elements, 50 boilerplate words, 6 text boxes, 15 text areas, 1 dates, 9 checkboxes, 23 check lists, 279 total clicks
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