Examination – ProductiveMedic

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Examination

- 1) Select the appropriate checkboxes.
- Examination
  - General
  - Obs
  - ENT
  - CVS
  - RS
  - GI
  - Neurology
- MSK Examination
  - MSK
  - Neck
  - Shoulder
  - Arm
  - Elbow
  - Wrist
  - Hand
  - Back
  - Hip
  - Leg
  - Knee
  - Calf
  - Ankle
  - Foot
- 2) Select the appropriate examination detail from the drop-downs.
- 3) Edit the text boxes to reflect your examination findings.
- General exam
- General short
- General medium
  - General - Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused. No JACCOL.
- General long
  - General - Looks well, not distressed, not SOB, well-hydrated, alert and orientated, not confused. No JACCOL. No rash - No meningism - No photophobia - No neck stiffness - Kernigs negative.
- Newline
  - -----
- Observations
- General obs
- Newline
  - -----
- ENT exam
- ENT short
- ENT medium
  - ENT - RTM and canal normal. LTM and canal normal. Throat - pink no exudate.
- ENT long
  - ENT - RTM and canal normal. LTM and canal normal, No mastoiditis. Throat pink no exudate - Uvula central - No quinsy. Nose - No obstruction - No discharge - No blood. No cervical LN.
- Newline
  - -----
- CVS exam
- CVS short
- CVS medium
  - CVS - Sinus rhythm, JVP not raised, HS I+II+0 no murmurs. Calves soft non-tender, no calf, or ankle swelling.
- CVS long
  - CVS - Sinus rhythm, JVP not raised, HS I+II+0 no murmurs. Calves soft non-tender, no calf, or ankle swelling. Normal peripheral pulses, normal CRT and normal sensation.
- Newline
  - -----
- RS exam
- RS short
- RS medium
  - Chest - No respiratory distress. Good air entry with normal breath sounds - No crepitations or wheeze.
- RS long
  - Chest - No respiratory distress - No nasal flaring or accessory muscle use. Trachea central. Normal symmetrical chest expansion. Normal percussion note. Good air entry with normal breath sounds - No crepitations or wheeze. No vocal fremitus.
- Newline
  - -----
- GI exam
- GI short
- GI medium
  - Abdomen - Soft and non-tender - No rebound, guarding or rigidity. No palpable masses, hernia, or distension. No palpable organomegaly - No palpable LKKSB. No AAA felt - Normal femoral pulses. BS normal.
- GI long male
  - Abdomen - Soft and non-tender - No rebound/guarding/rigidity. No masses/hernia/distension. No palpable organomegaly - No palpable LKKSB. No AAA felt - Normal femoral pulses. BS normal. - PR examination - Normal external exam - Normal anal tone - Normal non-tender benign feeling prostate with normal sulcus - No masses - Soft stool in the rectum. No blood or malaena on the glove. - Scrotal exam - Normal non-tender testes/epididymis - No swelling - No masses - No LN. - Urine dip - NAD.
- GI long female
  - Abdomen - Soft and non-tender - No rebound/guarding/rigidity. No masses/hernia/distension. No palpable organomegaly - No palpable LKKSB. No AAA felt - Normal femoral pulses. BS normal. - PR examination - Normal external exam - Normal anal tone - No masses - soft stool in the rectum. No blood or malaena on the glove. - Vaginal examination - No vulval masses or ulceration. Normal looking cervix on speculum exam - No bleeding or discharge. Normal bimanual exam - No adnexal or uterine masses or tenderness. - Urine dip - NAD. - Urine pregnancy test - Negative.
- Newline
  - -----
- Neuro exam
- Neuro short
- Neuro medium
  - Neurology - Gait normal, CN II-XII normal, Rhomberg's negative. - PNS - Tone, Power & Reflexes normal in all four limbs - No focal neurology.
- Neuro long
  - Neurology - Alert and orientated in TPP - Normal fluent speech - Normal cognition. PERLA - Visual field normal - Normal eye movement - No ptosis. Normal facial sensation bilaterally. Normal muscles of mastication and facial expression. Hearing is intact to finger rub bilaterally. Palate elevates symmetrically. Sternocleidomastoid and trapezius strength is 5/5 bilaterally. Tongue protrudes midline without atrophy or fasciculations. Motor - Normal tone and bulk in all 4 limbs - No pronator drift - Power 5/5 and FROM all 4 limbs in flexion and extension. Reflexes - 2+ in the biceps, triceps, patellae and ankles bilaterally. Sensation - Normal light touch/pinprick and proprioception in all 4 limbs. Coordination - Normal rapid alternating movements - Normal finger-to-nose and heel-to-shin test bilaterally. Gait - Normal stride/arm swing and turns. Romberg's sign is absent.
- Newline
  - -----
- MSK exam
- MSK short
- MSK medium
  - MSK - Gait normal. Arms normal. Legs normal. Spine normal. No synovitis. No abnormal findings.
- MSK long
  - MSK - Gait normal. Spine: no deformities, FROM. Joints: No swelling/erythema/deformity, normal FROM, normal function. Muscles: no tenderness/weakness/wasting, reflexes and sensation normal.
- Newline
  - -----
- Neck exam
- Neck short
- Neck medium
  - Neck - No spinal deformity, No bony/muscle tenderness, Good ROM, No spasm. Shoulder NAD UL NV intact- Normal tone/power/reflexes, No signs of myelopathy.
- Neck long
  - Neck - No spinal deformity, No bony/muscle tenderness, Good ROM, No spasm. Non-tender cervical paraspinal muscles. Shoulders FROM. Normal tone, power 5/5 in both arms, co-ordination normal. Reflexes: normal ++ in the biceps & triceps. No finger jerks. No myelopathy. Normal sensation and pules. Legs: normal tone, power and reflexes. Plantars- down.
- Newline
  - -----
- Shoulder exam
- Shoulder short
- Shoulder medium
  - Shoulder - No bruising/erythema/swelling/tenderness/muscle wasting Good painless FROM, No crepitus, Joint stable. No impingement or painful arc.
- Shoulder long
  - Shoulder - No bruising/erythema/swelling/tenderness/muscle wasting Normal flexion /extension /internal and external rotation. Normal abduction with No impingement or painful arc. Normal tone, power 5/5 in both arms, co-ordination normal. Reflexes: normal in the biceps & triceps. Normal sensation and pulses.
- Newline
  - -----
- Arm exam
- Arm short
- Arm medium
  - Arm - No bruising/erythema/swelling/tenderness/muscle wasting Joints: No deformity/swelling and painless FROM. Normal strength and NV intact.
- Arm long
  - Arm - No Elbow/Wrist/MCP/PIP/DIP deformity/synovitis. No muscle wasting/skin changes/erythema/cellulitis/rash. No tendonitis/scaphoid tenderness. Normal tone, power and reflexes. Tinel's/Phalen's negative. Elbow flexion/extension normal. Normal wrist pronation /supination. Normal hand/pincer grip. Normal sensation and pulses.
- Newline
  - -----
- Elbow exam
- Elbow short
- Elbow medium
  - Elbow - No bruising/erythema/swelling/tenderness/muscle wasting. Good painless FROM, No crepitus, Joint stable.
- Elbow long
  - Elbow - No bruising/erythema/swelling/tenderness/muscle wasting. No olecranon bursitis. No joint infection. Stable joint. Normal flexion /extension. Normal wrist pronation /supination. No medial/lateral epicondyl tenderness/pain on resistance. Tinels negative. NV intact.
- Newline
  - -----
- Wrist exam
- Wrist short
- Wrist medium
  - Wrist - No bruising/erythema/swelling/tenderness/muscle wasting No tendonitis or scaphoid tenderness and painless FROM. NV intact.
- Wrist long
  - Wrist - No Wrist/MCP/PIP/DIP deformity/synovitis. No muscle wasting/skin changes/erythema/cellulitis/rash. No tendonitis/scaphoid tenderness. Normal tone, power and reflexes. Tinel's/Phalen's negative. Normal ROM /pronation /supination. Normal hand/pincer grip. Normal sensation and pulses.
- Newline
  - -----
- Hand exam
- Hand short
- Hand medium
  - Hand - No bruising/erythema/swelling/tenderness/muscle wasting No tendonitis or scaphoid tenderness. No synovitis and FROM. NV intact.
- Hand long
  - Hand - No muscle wasting/skin changes/cellulitis/ulceration No Wrist/MCP/PIP/DIP deformity/synovitis. No tendonitis/scaphoid tenderness. Normal wrist ROM /pronation /supination. Tinel's/Phalen's negative. Normal hand/pincer grip. Thumb NAD: ligaments stable. Normal sensation and pulses.
- Newline
  - -----
- Back exam
- Back short
- Back medium
  - Back - No deformity, No bony tenderness, Non-tender paraspinal muscles, good ROM. SLR normal bilaterally, reflexes normal, No foot drop- power normal- walking on heels and toes normally.
- Back long
  - Back - No deformity, No bony tenderness, Non-tender paraspinal muscles, Good ROM. SLR: R leg = normal, L leg = normal. Tone normal, no clonus. Power: normal 5/5. No foot drop- Normal heel & toe walking, Reflexes: knee and ankle normal bilaterally with down going plantars. Sensation normal. PR: normal perineal sensation and anal tone.
- Newline
  - -----
- Hip exam
- Hip short
- Hip medium
  - Hip - Gait normal. No leg shortening/rotation. No bruising/erythema/swelling/tenderness/muscle wasting. Good painless FROM, No crepitus.
- Hip long
  - Hip - Weight-bearing and walking. Gait normal. No leg shortening /rotation. No hip bruising/swelling/tenderness/muscle wasting. Good painless FROM at hip and knee. SLR normal. No skin changes/cellulitis/varicose veins/ulceration Calves soft non-tender, R=L no swelling, no DVT Normal perfusion, good cap refill, palpable peripheral pulse.
- Newline
  - -----
- Leg exam
- Leg short
- Leg medium
  - Leg - Weight-bearing and walking. Gait normal. No bruising/erythema/swelling/tenderness/muscle wasting. Joints: No deformity/swelling and painless FROM. Normal strength and NV intact.
- Leg long
  - Leg - Weight-bearing and walking. Gait normal. No leg shortening /rotation. No skin changes /cellulitis /varicose veins /ulceration. Calves soft non-tender, R=L no swelling, no DVT. Joints: No swelling /erythema /deformity, normal FROM. SLR normal. Normal power. No localised soft tissue swelling /Baker's cyst. Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal.
- Newline
  - -----
- Knee exam
- Knee short
- Knee medium
  - Knee - Weight-bearing and gait normal. No bruising/erythema/swelling/tenderness/muscle wasting. Good painless FROM, no crepitus, ligaments stable, McMurray's negative. The extensor mechanism is intact. Calves soft non-tender, R=L no swelling, no DVT.
- Knee long
  - Knee - Weight-bearing and gait normal. No bruising/erythema/swelling/tenderness/muscle wasting. Good painless FROM, no crepitus, ligaments stable, McMurray's negative. The extensor mechanism is intact. SLR normal. Hip NAD. Calves soft non-tender, R=L no swelling, no DVT. No localised soft tissue swelling /Baker's cyst. No skin changes /cellulitis /varicose veins /ulceration. Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal.
- Newline
  - -----
- Calf exam
- Calf short
- Calf medium
  - Calf - soft non-tender, R=L no swelling, no DVT, Achilles intact. No localised soft tissue swelling /Baker's cyst. No skin changes /cellulitis /varicose veins /ulceration Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal.
- Calf long
  - Calf - soft non-tender, R=L no swelling, no DVT, Achilles intact. No localised soft tissue swelling /Baker's cyst. Knee: good painless FROM, no crepitus, ligaments stable, McMurray's negative. The extensor mechanism is intact. SLR normal. Hip NAD. No skin changes /cellulitis /varicose veins /ulceration Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal.
- Newline
  - -----
- Ankle exam
- Ankle short
- Ankle medium
  - Ankle - Weight-bearing and normal gait. No swelling /erythema /tenderness /deformity, normal FROM. Achilles is intact. Calves soft non-tender, R=L no swelling, no DVT. No skin changes /cellulitis /varicose veins /ulceration Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal.
- Ankle long
  - Ankle - Weight-bearing and normal gait. No swelling /erythema /tenderness /deformity, normal FROM. Achilles is intact. Achilles is intact > Simmonds' triad normal: Normal ankle dangle, no gap in the tendon, and foot plantar flexes normally on calf squeeze. Calves soft non-tender, R=L no swelling, no DVT. No skin changes /cellulitis /varicose veins /ulceration Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal.
- Newline
  - -----
- Foot exam
- Foot short
- Foot medium
  - Foot - Weight-bearing and gait normal. No skin changes /cellulitis /ulceration /swelling. No tenderness or synovitis, FROM. Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal. Ankle: No swelling /erythema /tenderness /deformity, normal FROM. Achilles is intact.
- Foot long
  - Foot - Weight-bearing and gait normal. No skin changes /cellulitis /ulceration /swelling. No tenderness or synovitis, FROM. Normal perfusion, good cap refill, palpable peripheral pulses, sensation normal. Ankle: No swelling /erythema /tenderness /deformity, normal FROM. Achilles is intact > Simmonds' triad normal: Normal ankle dangle, No gap in the tendon, Foot plantar flexes normally on calf squeeze. Calves soft non-tender, R=L no swelling, no DVT. Knee NAD. The extensor mechanism is intact. SLR normal. Hip NAD.
- Newline
  - -----
- 4) Click the button to review your clinical note.

- 5) Edit, select (Ctrl A), copy (Ctrl C) and paste (Ctrl V) the text below into the consultation template or directly into the clinical notes. {GENERAL-Short:5:value}{Medium:6:value}{Long:7:value}{Newline:9:value}{OBSERVATION:11:value}{Newline:13:value}{ENT-Short:15:value}{Medium:16:value}{Long:17:value}{Newline:19:value}{CVS-Short:21:value}{Medium:22:value}{Long:23:value}{Newline:25:value}{RS-Short:27:value}{Medium:28:value}{Long:29:value}{Newline:31:value}{GI-Short:33:value}{Medium:34:value}{Long:35:value}{Long:36:value}{Newline:38:value}{NEURO-Short:40:value}{Medium:41:value}{Long:42:value}{Newline:44:value}{MSK-Short:46:value}{Medium:47:value}{Long:48:value}{Newline:50:value}{NECK-Short:52:value}{Medium:53:value}{Long:54:value}{Newline:56:value}{SHOULDER-Short:58:value}{Medium:59:value}{Long:60:value}{Newline:62:value}{ARM-Short:64:value}{Medium:65:value}{Long:66:value}{Newline:68:value}{ELBOW-Short:70:value}{Medium:71:value}{Long:72:value}{Newline:74:value}{WRIST-Short:76:value}{Medium:77:value}{Long:78:value}{Newline:80:value}{HAND-Short:82:value}{Medium:83:value}{Long:84:value}{Newline:86:value}{BACK-Short:88:value}{Medium:89:value}{Long:90:value}{Newline:92:value}{HIP-Short:94:value}{Medium:95:value}{Long:96:value}{Newline:98:value}{LEG-Short:100:value}{Medium:101:value}{Long:102:value}{Newline:104:value}{KNEE-Short:106:value}{Medium:107:value}{Long:108:value}{Newline:110:value}{CALF-Short:112:value}{Medium:113:value}{Long:114:value}{Newline:116:value}{ANKLE-Short:118:value}{Medium:119:value}{Long:120:value}{Newline:122:value}{FOOT-Short:124:value}{Medium:125:value}{Long:126:value}{Newline:128:value}