CoreCodeExamStandard

  • [3] [b]EXAM:[/b]
    • [2] [b]VITALS:[/b] (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient): 
      • [::- General Commentary on Vitals Signs -::]
        • Vital signs in/near range of normal, not suggestive of acute emergent pathology. 
        • Elevated BP: Advised patient to follow up for recheck/eval with PMD for elevated BP, asymptomatic. 
      • [::- Interpretation of Vital Signs -::]
        • [01] HR: 
          • [01] [normal HR,tachycardic,bradycardic;exam_hr]
            • good chronotropic response
            • asymptomatic, 
          • __
        • [01] BP: 
          • [01] normotensive. 
          • hypertensive
            • [01] (attempted to inform pt to advise to f/u with PMD). 
          • hypotensive.
          • __
        • [01] O2 sat:
          • [01] [no, ;exam_o2] hypoxia on my interpretation of pulse oximetry, 
          • peri baseline O2 sat, 
          • __
        • [01] RR: 
          • [01] [normal,tachypnic,bradypnic;exam_rr] respiratory rate, 
          • __
        • __
    • [3] [b]PHYSICAL EXAM:[/b]
      • [01] [2] Constitutional:
        • [01] well-nourished, 
        • [no,mild,moderate,severe;exam_distress] distress, 
        • __
      • [01] [2] HEENT:
        • [01] vision grossly intact,
        • [01] hearing grossly intact.,
        • vision
          • 20/20 bilaterally, 
          • __
        • EOM intact, 
        • PERRLA [::- pupils equal, round, reactive to light and accommodation -::]
        • intraocular pressures wnl,  [::- normal pressures under 20 -::]
        • confrontation visual fields intact,  [::- check for no visual field defect -::]
        • external examination non-remarkable, 
        • slit lamp exam:
          • lids/lashes lacrimal system without lesions, 
          • conjunctiva/sclera: white and quiet, no injections, 
          • cornea: clear, 
          • anterior chamber: no cell or flare, 
          • iris: round pupil, 
          • lens: clear, no cataracts, 
          • anterior vitreous: no inflammation/hemorrhage, 
          • __
        • fundoscopic exam:
          • no papillary edema, 
          • no splinter hemorrhage, 
          • __
        • fluorescein exam:
          • no areas of uptake, 
          • __
        • __
      • [01] [2] Cardiovascular:
        • RRR, 
        • tachycardic, 
        • [01] no r/m/g, 
        • [01] no LE swelling, 
        • no LE asymmetry, 
        • no JVP, 
        • __
      • [01] [2] Pulmonary:
        • [01] Lungs CBTA, 
        • [01] No respiratory distress, non-labored breathing
        • [01] Speaking comfortably in full sentences, 
        • symmetric breath sounds
        • wheezing,
          • (inspiratory and expiratory),
          • (expiratory only), 
        •  significant decreased aeration
        • rales, 
          • throughout, 
          • at bases bilaterally, 
          • __
        • rhonchi, 
        • respiratory distress,
          • mild, 
          • moderate, 
          • severe, 
        • __
      • [01] [2] GI:
        • [01] abdomen soft,
        • [01] abdomen non-tender in all 4 quadrants, 
        • TTP diffusely
        • TTP in RUQ, 
        • TTP in RLQ, 
        • TTP in LLQ, 
        • TTP in LUQ, 
        • TTP in epigastric region, 
        • __
      • [01] [2] Neuro:
        • [01] Normal LOC.
        • [01] No gross focal neurological deficits. 
        • Somnolent though protecting airway.
        • CN II-XII intact, 
        • no facial asymmetry
        • PERRL, 
        • strength intact throughout, 
        • sensation grossly intact throughout, 
        • normal reflexes, 
        • ambulatory, 
        • with steady gate,
        • no dysmetria, 
        • no dysarthria, 
        • __
      • [01] [2] MSK:
        • [01] no deformities, 
        • [01] moving all extremities, 
        • [ ,non;exam_ambulation] ambulatory, __
        • Focused exam at affected area __
          • [01] nuero intact
          • [01] muscular intact
          • [01] vascular intact
          • no deformities, 
          • [ ,no;exam_bonettp] bony tenderness to palpitation __
          • [ ,no;exam_range] full range of motion, __]
          • __
        • __
      • [01] [2] Pysch:
        • [01] Normal speech. 
        • [01] Demonstrates linear thinking. 
        • [no,positive for;exam_SI] SI, 
        • [no,positive for HI;exam_HI] HI. 
        • Exam / appearance / presentation consistent with gravely disabled. 
        • No AH/VH. 
        • Agitated. 
        • Confused. 
        • __
      • [2] GU exam:
        • [2] Male specific exam:
          • Exam chaperoned
            • by __
          • Testicular exam:
            • no testicular tenderness, 
            • normal testicular lie,
            • able to elicit cremaster reflex,
            • __
          • Penile exam:
            • no discharge at meatus
            • non-erect
            • __
          • Prostate exam:
            • enlarged prostate
            • [not,__;gu_prostate] bogginess and tenderness 
            • __
        • [2] Female specific exam:
          • Exam chaperoned, 
            • by __, 
          • no CMT, 
          • no adnexal TTP,
          • no abnomral discharge
          • no active vaginal bleeding, 
          • vaginal bleeding from os, [mild bleeding,moderate bleeding,severe bleeding;exam_bleeding]
          • atraumatic, no cervical lacerations
          • __
        • [2] Rectal exam:
          • Exame chaperoned
            • by __
          • [01] guiac [negative,positive without flank blood,positive with BRBPR;gu_guiac]
          • [01] brown stool in vault, 
          • [01] no visible external hermorroids, 
          • [01] no palpable internal hemorroids, 
          • thought appreciate limited sensitivity of DRE
          • __

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