PWF2a – PE (non-MSK) – Physician Workflow Part 2a

PHYSICAL EXAM

virtual visit abbreviated exam -Chaperone* -
-Vitals Review* -
-General - * more detail

←freetext ↓quickpicks↓ well developed well nourished A&Ox4 NAD MILDLY ILL SLEEPY APPEARS CONFUSED APPEARS LETHARGIC CACHECTIC APPEARANCE APPEARS OLDER THAN STATED AGE
-HEENT - * more detail

←freetext ↓quickpicks↓ normocephalic atraumatic conjunctiva clear sclerae aninteric TMs with clearly visible landmarks nares patent b/l turbinates nonedematous/nonerythematous b/l mucous membranes moist throat nonerythematous/noninjected good dentition R CONJUNCTIVAL ERYTHEMA L CONJUNCTIVAL ERYTHEMA R TM OPAQUENESS & LOSS OF LANDMARKS R TM VIEW OBSCURRED BY CERUMEN L TM OPAQUENESS & LOSS OF LANDMARKS L TM VIEW OBSCURRED BY CERUMEN NASAL SEPTUM DEVIATION R TURBINATE EDEMA R TURBINATE ERYTHEMA L TURBINATE EDEMA L TURBINATE ERYTHEMA NASAL DISCHARGE PHARYNGEAL ERYTHEMA/INJECTION PHARYNGEAL COBBLESTONING TONSILS INJECTED/EDEMATOUS TONSILS WITH EXUDATE GLOSSAL HYPERTROPHY UVULAR DEVIATION
-Neck - * more detail

←freetext ↓quickpicks↓ soft/supple no JVD no thyromegaly no tender/enlarged lymph nodes R ANTERIOR CHAIN LYMPHADENOPATHY R POSTERIOR CHAIN LYMPHADENOPATHY L ANTERIOR CHAIN LYMPHADENOPATHY L POSTERIOR CHAIN LYMPHADENOPATHY JUGULAR VENOUS DISTENSION GOITER
-Chest - * more detail

←freetext ↓quickpicks↓ normal rise and fall B/L no accessory muscle use INTERCOSTAL RETRACTIONS SUPRACOSTAL RETRACTIONS INFRACOSTAL RETRACTIONS PECTUS EXCAVATUM PECTUS CARINATUM
-Breast - *

more detail
-R Breast: normal contour, no nodules, no concerning palpable masses, no significant tenderness to palpation no enlarged axillary lymph nodes, no skin dimpling, no nipple discharge fibrocystic changes skin dimpling mastectomy changes breast tenderness to palpation muscle tenderness mass palpable nipple discharge axillary adenopathy

←L breast freetext
-L Breast: normal contour, no nodules, no concerning palpable masses, no significant tenderness to palpation no enlarged axillary lymph nodes, no skin dimpling, no nipple discharge fibrocystic changes skin dimpling mastectomy changes breast tenderness to palpation muscle tenderness mass palpable nipple discharge axillary adenopathy

←R breast freetext
-Heart/CV - * more detail

←freetext ↓quickpicks↓ RRR no ectopy normal S1/S2 No M/R/G No S3/S4 auscultated no friction rub INFREQUENT ECTOPY FREQUENT ECTOPY MURMUR AUSCULTATED - GRADE /6 HEARD BEST AT
-Lungs/Pulm - * more detail

←freetext ↓quickpicks↓ CTAB BSE b/l no wheezes no crackles no rhonchi WHEEZING- EXPIRATORY INSPIRATORY B/L LUNGS R LUNG L LUNG DIFFUSE LOWER FIELD(S) UPPER FIELD(S); CRACKLES- EXPIRATORY INSPIRATORY B/L LUNGS R LUNG L LUNG DIFFUSE LOWER FIELD(S) UPPER FIELD(S); RHONCHI- EXPIRATORY INSPIRATORY B/L LUNGS R LUNG L LUNG DIFFUSE LOWER FIELD(S) UPPER FIELD(S); BREATH SOUNDS DIMINISHED- B/L LUNGS R LUNG L LUNG DIFFUSE LOWER FIELD(S) UPPER FIELD(S)
-Abdomen - * more detail

←freetext ↓quickpicks↓ soft nontender nondistended no voluntary/involuntary guarding no rigidity no rebound bowel sounds present in all 4 quadrants TTP- MILD MODERATE EXQUISITE OUT OF PROPORTION TO EXAM RUQ EPIGASTRIC AREA LUQ RLQ LLQ PERIUMBILICAL SUPRAPUBIC; BOWEL SOUNDS- HYPOACTIVE HYPERACTIVE RUQ LUQ RLQ LLQ DIFFUSELY; PALPABLE MASS- APPROXIMATE SIZE - CM, RUQ LUQ RLQ LLQ MIDLINE PERIUMBILICAL PULSATILE; VISIBLE SCAR(S)- RUQ EPIGASTRIUM LUQ RLQ LLQ UMBILICAL PERIUMBILICAL MIDLINE SUPRAPUBIC REPORTED AS PRIOR PFANNENSTIEL/C-SEC REPORTED AS PRIOR LAPAROSCOPIC PORT(S) REPORTED AS PRIOR HERNIA REPAIR REPORTED AS PRIOR/HEALED TRAUMA
-GU - *Male

for skin masses use 'Skin' section more detail

←freetext ↓quickpicks↓ penis normal appearance penis normal palpatory texture no penile discharge scrotum normal appearance b/l no scrotal ecchymosis/edema/erythema scrotum freely mobile b/l testes descended b/l no palpatory testicular mass b/l cremasteric reflex intact b/l no palpable epididymal mass b/l no palpable inguinal hernia on exam b/l no tender inguinal lymphadenopathy b/l PENILE DISCHARGE- ; URETHRAL MEATUS- ; PENIS TENDERNESS TO PALPATION SCROTAL TENDERNESS TO PALPATION- ; PALPABLE SCROTAL MASS- palpable mass located location/size/texture; INGUINAL HERNIA EXAM- palpable inguinal mass with valsalva on
-GU - *Female

for skin masses use 'Skin' section more detail

←freetext ↓quickpicks↓ normal appearance of external genitalia normal appearance of vagina normal appearance of vaginal mucosa no abnormal vaginal discharge no abnormal cervical discharge no CMT no uterine tenderness no adnexal tenderness IUD string visualized no tender inguinal lymphadenopathy b/l VAGINAL DISCHARGE- ; VAGINAL MUCOSA- ; VAGINAL TENDERNESS CERVICAL MOTION TENDERNESS CERVICAL DISCHARGE- ; ADNEXAL TENDERNESS ADNEXAL MASS- ;
-Skin - *
more detail

←freetext ↓quickpicks↓ warm dry intact no edema no erythema no induration no ecchymosis no concerning lesions ACROCYANOSIS JAUNDICE-
DIFFUSE/NON-FOCAL LESION(S)-
-Affected area(s)- face forehead anterior neck posterior neck anterior trunk posterior trunk R shoulder l shoulder R arm L arm R elbow L elbow R forearm L forearm R wrist L wrist R hand dorsum L hand dorsum R palm L palm R inguinaL area L inguinaL area R hip L hip R thigh L thigh R knee L knee R leg L leg R ankle L ankle R foot dorsum L foot dorsum R foot sole L foot sole
-Description- macular papular raised(plaques) patches lacey appearance scattered clustered rough texture smooth texture erythematous ecchymosis skin/flesh colored hyperpigmented hypopigmented non-blanching scaling crusting excoriated ulcerated non-ulcerated
-Additional details-

FOCAL/ISOLATED LESION(S)-
-#1
* -Location: - area- area- , anterior posterior medial lateral, aspect- , anterior posterior medial lateral aspect- , anterior posterior medial lateral, aspect- , anterior posterior medial lateral, aspect- aspect- - - - - , palmar/volar dorsal medial lateral aspect, digit, - , plantar dorsal medial lateral aspect, digit,
-Description: macule papule patch plaque palpable lump visible wound visible lump (concerning for infection)
-Size/diameter:
-Characteristics: rough smooth firm soft mobile fixed pedunculated
-Color: ,
-Borders:
-Characteristics - erythema edema induration fluctuance tenderness to palpation drainage - purulent serous sanguinous/bloody
-Tissue layers damaged/affected - epidermis dermis subcutaneous layer muscle/tendon periosteum/bone
-Hemostatic -
-Wound approximation -
-Debris/foreign body present -
-Other details:
-#2
* -Location: - area- area- , anterior posterior medial lateral, aspect- , anterior posterior medial lateral aspect- , anterior posterior medial lateral, aspect- , anterior posterior medial lateral, aspect- aspect- - - - - , palmar/volar dorsal medial lateral aspect, digit, - , plantar dorsal medial lateral aspect, digit,
-Description: macule papule patch plaque palpable lump visible wound visible lump (concerning for infection)
-Size/diameter:
-Characteristics: rough smooth firm soft mobile fixed pedunculated
-Color: ,
-Borders:
-Characteristics - erythema edema induration fluctuance tenderness to palpation drainage - purulent serous sanguinous/bloody
-Tissue layers damaged/affected - epidermis dermis subcutaneous layer muscle/tendon periosteum/bone
-Hemostatic -
-Wound approximation -
-Debris/foreign body present -
-Other details:
-#3
* -Location: - area- area- , anterior posterior medial lateral, aspect- , anterior posterior medial lateral aspect- , anterior posterior medial lateral, aspect- , anterior posterior medial lateral, aspect- aspect- - - - - , palmar/volar dorsal medial lateral aspect, digit, - , plantar dorsal medial lateral aspect, digit,
-Description: macule papule patch plaque palpable lump visible wound visible lump (concerning for infection)
-Size/diameter:
-Characteristics: rough smooth firm soft mobile fixed pedunculated
-Color: ,
-Borders:
-Characteristics - erythema edema induration fluctuance tenderness to palpation drainage - purulent serous sanguinous/bloody
-Tissue layers damaged/affected - epidermis dermis subcutaneous layer muscle/tendon periosteum/bone
-Hemostatic -
-Wound approximation -
-Debris/foreign body present -
-Other details:
-EXT - * more detail

←freetext ↓quickpicks↓ no gross deformities noted no cyanosis no clubbing peripheral pulses 2/4 x4 CLUBBING- DIGITS UPPER EXTREMITY GROSS DEFORMITY
-PSYCH - * more detail

←freetext ↓quickpicks↓ appropriate mood appropriate affect FLATTENED AFFECT INAPPROPRIATE MOOD PRESSURED SPEECH DISORGANIZED THOUGHT PROCESS TANGENTIAL THOUGHT PROCESS
-NEURO - * more detail

←freetext ↓quickpicks↓ mentating well moves all extremities equally well CN 2-12 grossly intact b/l normal sensorium all 4 extremities no gross motor deficits Romberg negative cerebellar testing normal DTRs 2/4 x4 gait testing without abnormalities
abnormals -Cranial Nerve Deficit(s)- I II III IV V VI VII VIII IX X XI XII
-Sensory Deficit(s)- R occipital R parietal R temporal R frontal R preauricular R postauricular L occipital L parietal L temporal L frontal L preauricular L postauricular R mandibular angle R cheek R nasal bridge R periorbital R perioral chin submental R submandibular L mandibular angle L cheek L nasal bridge L periorbital L perioral L submandibular Neck anterior Neck posterior Neck medial Neck lateral R shoulder L shoulder Anterior chest/trunk Posterior chest/trunk Abdomen R buttocks L buttocks Perianal Gluteal cleft R inguinal L inguinal Penis R scrotum L scrotum R labia majora R labia minora R perilabial area L labia majora L labia minora L perilabial area periclitoral area mons pubis perineum R arm R elbow R forearm R wrist R hand/finger(s) L arm L elbow L forearm L wrist L hand/finger(s) R hip R thigh R knee R leg R ankle R foot/toe(s) L hip L thigh L knee L leg L ankle L foot/toe(s) description of deficits
-Motor Strength-
-R Upper Extremity- /5
-L Upper Extremity- /5
-R Lower Extremity- /5
-L Lower Extremity- /5
-Reflexes-
-Biceps- /4
-Triceps- /4
-Bracioradialis- /4
-Patellar- /4
-Achilles- /4
-Cerebellar Testing- POSITIVE ROMBERG PRONATOR DRIFT IMPAIRED FINGER-TO-NOSE IMPAIRED HAND PRONATE/SUPINATE IMPARIED HEEL-TO-SHIN cerebellar deficits freetext
-Gait- HEMIPLEGIC DIPLEGIC NEUROPATHIC CHOREIFORM ATAXIC PARKINSONIAN ANTALGIC

-ADDITIONAL EXAM -

PWF2a – PE (non-MSK) – Physician Workflow Part 2a

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