AUC Macros: PE, Physical Exam
PE: Telehealth - Video
Exam was performed during video visit by direct visualization and questioning.
Constitution: Well-developed, no acute distress.
Ears: No hearing difficulties noted during video conversation.
Neck: Lymph nodes palpable on guided self-exam and mildly tender.
OPTION COUGH
Lungs: Speaking in full sentences, no labored breathing, not tachypneic, no cough during exam, no wheezing.
Lungs: Occasional coughs during the exam. Speaking in full sentences, no labored breathing, not tachypneic, no wheezing.
Skin: No rash or lesions visible on exposed skin.
Neuro: Moving all extremities, Alert and Oriented x4.
Psych: Normal affect, good mood.
Video Telehealth - CPT Codes
| Visit Duration |
Less than 5 min |
Avoid charting |
| Visit Duration |
5-10 min |
Use CPT Code 98016 |
| Visit Duration |
Greater than 10 min |
Use the following chart: |
| CPT Code |
New pt |
Established pt |
| straight forward |
98000 |
98004 |
| Low |
98001 |
98005 |
| Moderate |
98002 |
98006 |
| High |
98003 |
98007 |
Visit was performed via telehealth using secure video communication through Epic EMR. The patient was physically present in the state of California and gave consent to be examined via telehealth. The patient's identity was confirmed.
PE: Telehealth - Telephone
Exam was performed via telephone.
Constitution: No acute distress
Ears: No hearing difficulties noted during phone conversation.
Neck: Lymph nodes palpable on guided self-exam and mildly tender.
Lungs: Speaking in full sentences, no labored breathing, not tachypneic, no cough or wheezing heard.
Neuro: Alert and Oriented x4.
Psych: Normal affect, good mood, thought process is normal.
Telehealth - Audio Only - CPT Codes
| Visit Duration
|
| CPT Code
| type
|
| 5-10 minutes |
CPT Code |
99441 |
Audio only |
| 11-20 minutes |
CPT Code |
99442 |
Audio only |
| 21-30 minutes |
CPT Code |
99443 |
Audio only |
Telehealth - Audio Only - CPT Codes (Use these for Premise)
| Visit Duration |
| under 5 min |
Avoid charting |
| 5-10 min |
Use CPT Code 98016 |
| Greater than 10 min |
Use the following chart: |
| CPT Code |
New pt |
Established pt |
| straight forward |
98008 |
98012 |
| Low |
98009 |
98013 |
| Moderate |
98010 |
98014 |
| High |
98011 |
98015 |
Visit was performed via audio telehealth using telephones. The patient was physically present in the state of California and gave consent to be examined via telehealth. The patient's identity was confirmed.
PE Abdominal pain 1
GENERAL: NAD, speaking full sentences
VSS, afebrile
SKIN: PWD, no diaphoresis, cyanosis or pallor
HEAD: NC, AT
EYES: pupils PERRL and EOMI
NECK: supple, no LAD. no meningismus
PULM: CTA bilaterally, no rales, rhonchi or wheezing
CV: RRR, no MGR
GI: flat/obese without distention. No surface trauma, scars, incisions or rash. +BS. No HSM. No mass. NT all four quadrants. No guarding, rebound or rigidity to palpation. NT to epigastric area. Neg Murphy's sign. No periumbilical tenderness. NT over Mcburney's point. No suprapubic tenderness or distention. No CVAT. Good femoral pulses bilaterally.
NEURO: A&O x 4, good insight and judgement.
PE Basic 1
GEN: alert and oriented x 4, in NAD, good personal hygiene, appears well hydrated & well nourished
EYES: Sclera white, conjunctiva non-injected;
CV: Audible S1/S2, RRR, no adventitious heart sounds;
PULM: CTA in upper & lower lobes bilaterally. No cough, work of breathing, wheezes or crackles;
GI: No apparent abdominal distention;
MSK: Normal strength & muscle tone observed;
DERM: No rash, ecchymosis or petechiae;
NEURO: CN II-XII grossly intact. No focal neurological deficits;
PSYCH: Mood & affect are appropriate. No signs of mental deficits. No SI or HI.
PE URI (I use this one a lot at Urgent Care)
OPTION GENERAL
[Fussy pediatric]
GEN: alert, attentive, but fussy. Exam quality low due to fussiness and movement. Good personal hygiene. Appears well hydrated & well nourished;
[Playful pediatric]
GEN: alert, attentive, and playful. Good personal hygiene. Appears well hydrated & well nourished;
[adult]
GEN: alert and oriented x 4, in NAD, good personal hygiene, appears well hydrated & well nourished;
EYES: Sclera white, conjunctiva non-injected;
OPTION EARS
EARS: TMs not bulging, with visible landmarks, and no visible fluid. Canals not erythematous;
EARS: Bilateral external ear without erythema, lesions, or tenderness to palpation. Internal canal without excessive cerumen buildup or erythema. No foreign bodies noted. TMs non-retracted, without fluid, pearly gray bilaterally. Auditory acuity appears WNL;
SINUS: No tenderness of the frontal or maxillary sinuses;
OPTION THROAT
THROAT: Pharyngeal mucosa pink/moist, without erythema, tonsils 1+ bilaterally, no exudate;
THROAT: Pharyngeal mucosa erythematous without exudate;
THROAT: No erythema or exudate;
OPTION NECK
NECK: No palpable nodes and not tender;
NECK: Palpable submandibular lymph nodes but without tenderness;
CV: RRR, no murmurs heard;
OPTION COUGH
PULM: CTA in upper & lower lobes bilaterally.
No cough, work of breathing, wheezes or crackles;
PULM:
Mild cough. CTA in upper & lower lobes bilaterally. No work of breathing, wheezes or crackles;
GI: No apparent abdominal distention;
DERM: No rash, ecchymosis or petechiae;
NEURO: CN II-XII grossly intact. No focal neurological deficits;
PSYCH: Mood & affect are appropriate for age. No signs of mental deficits;
PE Adult General Exam w/o GU1
GENERAL: A&Ox4, in NAD, normal level of consciousness, good personal hygiene, in no apparent distress, appears well nourished.
HEAD: NC, AT; without tenderness, normal in size
EYES: Sclera is white. Conjunctiva is pink. No nystagmus, ptosis, or lid lag. No periorbital swelling or redness. EOMI. PERRLA.
EARS: Bilateral external ear without erythema, lesions, or tenderness to palpation. Bilateral Internal canal without excessive cerumen buildup or erythema. No foreign bodies noted. TMs were intact/no perforation, non-retracted, without fluid and pearly gray bilaterally.
NOSE: nasal mucosa is moist and pink. no nasal discharge. No foreign body. Septum is midline with normal turbinates.
SINUS: No tenderness to palpation of the frontal and maxillary sinuses
ORAL: Oral mucosa is moist without lesions. Normal tongue without any swelling or lesion. Dentition is good.
THROAT: tonsils are non-tender, without enlargement or exudates. pharynx is moist without erythema or exudates. uvula is midline. open airway.
NECK: Neck is supple without masses or lymphadenopathy. Trachea is midline. No JVD or Carotid bruits noted.
THYROID: Thyroid is symmetrical, smooth and nontender without masses.
RESPIRATORY: No increased work of breathing & respirations unlabored. No accessory muscle use. CTAB, No wheezes or crackles. Normal AP diameter.
CV: Hemodynamically stable. RRR. audible S1/S2. no adventitious heart sounds. Normal peripheral perfusion. 2+ peripheral pulses. Cap refill brisk, < 3 sec. no edema noted. Skin turgor normal.
GI: BS normoactive. soft, non-tender, non-distended. No hepato-splenomegaly. No masses. No rebound tenderness or guarding. Negative Murphy's sign, Psoas sign, Obturator sign. Bladder non-palpable. No CVA tenderness.
MSK: normal muscle tone/bulk, no deformities, normal range of motion, normal spine alignment. strength appears normal.posture wnl.
INTEGUMENTARY: Normal color and texture. No bruising, erythema, cyanosis. No lesions/gross rash visible or masses. Skin turgor normal.
EXTREMITIES: no varicose veins, no edema, no cyanosis no abnormal movements, no tremor, no rigidity, normal alignment, normal gait.
NEURO: CNI-XII intact, (2+) DTR, neurosensory WNL. no focal neurological deficit observed. normal gait. normal motor observed. normal speech observed. normal coordination observed. strength (5/5), UE/LE bilaterally. normal sensory observed.
PSYCHIATRIC: mood and affect are appropriate. Engaged in care. Thought processes logical, organized, relevant, understandable, coherent, and goal oriented. Perception, insight, and judgement not suggestive of psychosis, impairment, or disorientation. No SI or HI.
PE Pediatric Normal exam 1
Gen: well developed, well nourished child who is awake and active, interacts appropriately with surrounds and examiner, NAD
VS: WNL, afebrile
Skin: PWD, normal texture and turgor without rash or cyanosis
HEENT:
Head: NC, AT
Eyes: moist and bright, sclera and conjuctiva normal. PERRLA. EOMI
Ears: canals patent, TM's clear.
Nose: patent without nasal flare or rhinorrhea
Mouth/throat: MM moist. PP clear without lesions, exudates or erythema
Neck: supple, FROM. No LAD.
Chest: CTA, good lung volume
Heart: RRR, No MRG
Abd: soft, nondistended, NT. +BS. No masses or HSM
Back: without spinal or CVAT
Ext: FROM, good strength bil. NVI. No cyanosis or edema
MSK: Normal extremities & spine. No deformities. Normal gait. No clubbing, cyanosis, or edema.
NEURO: Normal muscle strength and tone. Normal motor function and balance. No focal deficits. ***Intact primitive reflexes.
GROWTH CHART: Following growth curve well in all parameters.
PE Breast and Female GU 1
BREAST/AXILLAE: Chaperoned exam of breast and Axillae. symmetrical, no visible or palpable masses, no dimpling, nipples everted without discharge, no discoloration
PELVIS: NT to palpation and stable to compression. No hernia,
GYN: Chaperoned exam of External genitalia WNL. No lesions, masses, rashes, erythema, bruising, edema, or discharge. Hair pattern WNL. Introitus WNL. Internal vaginal and cervical exam WNL. Cervix round, pink, nonfriable. Cervix without lesions, nodules, masses. Vaginal wall pink, without erythema, discharge, lesions, ulcerations, masses. No atrophy noted.
PAP smear is done without any pain or complication. Patient is tolerated well.
BIMANUAL: Vaginal walls smooth, no lesions, masses palpated. No cervical motion tenderness. Uterus and ovaries palpated without tenderness. No masses palpated. Good pelvic muscle strength.
RECTAL: Normal tone. No rectal wall tenderness or mass. No hemorrhoids. Stool is brown, no gross blood. hem occult test negative
PE GU Men Exam 1
Male Reproductive: Testicles firm, non-tender, without masses or lesions. Descended bilaterally. No induration, erythema, or edema. Penis is circumcised, without lesions or discharge. No hernias palpated in the inguinal canals.
Prostate: firm, non-tender, without nodules
Rectal: Rectal wall without nodules, masses, or tenderness. No internal or external hemorrhoids palpated or visualized. Good sphincter tone. No occult blood.
PE Headache-Dizziness-Neuro 1
Gen: awake and alert, not toxic appearing
VS: afebrile, not tachycardic
Skin: PWD, no lesions or rash, no petechiae
HEENT:
Head: NC, AT. no trigger points
Eyes: sclera and conjunctivae clear, corneas grossly clear, PERRLA. EOMI. no nystagmus. no ptosis. No photophobia. +/-Dix Hallpike
Ears: Bilateral external ear without erythema, lesions, or tenderness to palpation. Internal canal without excessive cerumen buildup or erythema. No foreign bodies noted. TMs non-retracted, without fluid, pearly gray bilaterally. no hemotympanum or battles sign. Auditory acuity appears WNL.
Nose/Face: no rhinorrhea, congestion. no frontal or maxillary sinus TTP. no asymmetry
THROAT: normal, without erythema, tonsillar inflammation or exudate. Normal tongue movement, Uvula midline
Neck: supple, FROM. NT. no LAD. no meningismus
Chest: CTA, good lung volume
Heart: RRR. no murmur, rub or gallop
Extremes: moves all extremities with good strength. normal gait.
Neck: no point tenderness, step off or deformity to firm palpation of the cervical spine at the midline. No spasm or paraspinal muscle tenderness. Trachea midline. carotids equal. No masses. FROM without limitation or pain
Neuro: A&O x 4, GCS 15. CN 2-12 grossly intact. Negative Kernig's sign, Negative Brudzinski's sign No focal neurological deficits. Normal sensation and motor exam. Normal DTR's. normal finger to nose coordination. speech clear, normal gait. no pronator drift. normal repetitive hand movement, heel-shin exam. Negative Romberg test. Normal heel-toe walking.
PE Face Injury/pain-Bell'sPalsy1
Gen: alert, in no distress.
VS: WNL, afebrile
Skin: PWD, no lesions. good texture and turgor.
HEENT:
Head: no scalp contusion, tenderness, open wounds, FB, bony step off or deformity
Eyes: PERRLA. EOMI. sclera and conjuctivae normal. No eyelid swelling or contusion. No periorbital ecchymosis(raccoon eye or black eye) or bony step-off.
Ears: canals clear. TM's clear. no hemotympanum or battles sign. No otorrhea.
Nose: no septum deviation, no rhinorrhea or septal hematoma. no nasal drainage or inflammation.
Mouth/throat: no lip swelling or contusion. No tongue laceration. no dental injury or infection. PP clear, patent airway
Face: symmetric. no soft tissue swelling or abrasions. No ecchymosis, contusions or open wounds. No bony step-off and deformity of forehead. no facial droop. no loss of nasolabial fold. No tmj. no jaw click
Neck: NT to firm midline palpation of posterior c-spine. FROM. no spasm or mass. No soft tissue swelling
Chest: CTA, good lung volume
Abd: soft, +BS, NT. no hsm
Back: no spinal or CVAT
Extrems: FROM, NT. good strength
Neuro: A&O x 4, GCS 15. CN 2-12 grossly intact. Negative Kernig's sign, Negative Brudzinski's sign No focal neurological deficits. Normal sensation and motor exam. Normal DTR's. normal finger to nose coordination. speech clear, normal gait. no pronator drift. normal repetitive hand movement, heel-shin exam. Negative Romberg test. Normal heel-toe walking.
PE Rash 1
Gen: alert, not toxic appearing
VSS, afebrile
Skin: ***
Head: NC, AT Eyes: PERRLA, EOMI, sclera and conjuctivae clear. No periorbital lesions, soft tissue swelling or erythema.
Ears: canals and TM's normal. No pre or postauricular LAD
Nose: without rhinorrhea
Face: symmetric
Mouth/Throat: MMM, PP clear. No mucosal lesions, strawberry tongue, palatine petechiae, vesicles, or Koplik's spots. open airway. no uvular or tonsillar swelling. normal tongue movement.
Neck: supple, FROM. No LAD
Chest: CTA, no wheezing or rhonchus, good lung volume, No chest wall retraction or accessory muscle use.
Heart: RRR, No MRG
Abd: soft, NT. +BS. No HSM
Back: no spinal or CVAT
Extrems: moves all extremities well with good strength, no peripheral edema. no calf tenderness.
PE Laceration 1
Gen: NAD, speaking full sentences
VS: WNL, afebrile
Skin: PWD, intact except below.
Head: NC, AT
Eyes: PERRLA, EOMI
Neck: supple, FROM
Chest: CTA, good lung volume
Heart: RRR, No MRG
Msk: + linear/curved, deep/superficial ~ long laceration in . No excessive bleeding. No foreign body or infection sign. No nail injury. Normal sensation and normal motor strength. Normal ROM. No tendon injury appreciated. Normal peripheral pulses . Normal peripheral filling.
PE Spine Exam 1
Gen: NAD, speaking full sentences
VS: WNL, afebrile
Skin: PWD, intact
Head: NC, AT
Eyes: PERRLA, EOMI
Chest: CTA, good lung volume
Heart: RRR, No MRG
ABD: NT, ND abdomen No abdominal bruit,
MSK: Normal skin color, no redness, warmth, swelling or ecchymosis.
Lumbar spine: decreased lordosis. No mass or scoliosis or kyphosis. No masses. No bony tenderness, step off or deformity to firm palpation at posterior midline. +/- tenderness of L3-5 spinous process and bilateral para-vertebral muscles. All ROM was full without any pain. Negative bilateral SLT.
Cervical Spine: No neck stiffness or torticollis. No masses. No bony tenderness, step off or deformity to firm palpation at posterior midline. Decreased lordosis. +/-spinous process and paravertebral muscle tenderness. +/- left/right trapezius tenderness. Full ROM without any pain.
Neuro: Normal sensation and motor exam. Normal DTR. No saddle anesthesia. Normal / antalgic gait
Normal peripheral pulses . Normal peripheral filling.
PE Hip Ankle Foot 1
Gen: NAD, speaking full sentences
VSS, afebrile, normotensive
Skin: PWD, intact except below.
HEENT: NC, AT. PERRL, EOMI. trachea midline
Chest: CTA, good lung volume
Heart: RRR, No MRG
MSK: pt able to bear weight and ambulate to treatment room.
*** ankle/foot/hip is without obvious asymmetry or deformity when compared to other side. No obvious rash, redness, warmth, drainage, ecchymosis, obvious trauma abrasion, laceration or soft tissue swelling. No bony tenderness to palpation. Normal ROM with/without pain .
Good dorsalis pedis and posterior tibial pulses. No calf tenderness. Negative Homan's sign.
Neuro: A&O x4 , good insight and judgment. Normal muscle strength and sensation exam.
PE Knee 1
Gen: NAD, speaking full sentences
VS: WNL, afebrile
Skin: PWD, intact except below.
Head: NC, AT
Eyes: PERRLA, EOMI
Neck: supple, FROM
Chest: CTA, good lung volume
Heart: RRR, no murmur. No calf tenderness.
MSK: normal tandem gait/antalgic gait.
+ tenderness in right/left knee medial/lateral aspect. + Swelling. No redness, warmth.
+Ballottement test,
knee flexion and extension were/not painful and full/ slightly restricted. Patellar movement full without any pain.
Negative-positive medial/lateral collateral ligament instability and pain with knee valgus/varus stress.
Negative- positive Mc Murray test.
Negative -positive anterior and posterior drawer test,
Normal sensation, motor strength of bilateral lower extremity. normal peripheral pulses. normal coloration of toes and foot.
PE Shoulder Pain 1
Gen: NAD, speaking full sentences
VS: WNL, afebrile
Skin: PWD, intact
HEENT: NC, AT. PERRL. EOMI. trachea midline
Chest: CTA, good lung volume
Heart: RRR, No MRG
Shoulder:
No evidence of deformity, ecchymosis, effusion or swelling without obvious asymmetry when compared to the other shoulder. No surface trauma, ecchymosis or crepitus. No axillary tenderness or LAD. No bony deformity or prominence of the humeral head. NT to palpation over clavicle, A.C joint, acromion, scapula or humeral head.
Range of motion of left/right/bilateral shoulder was full without any restriction except in
Neurovascular
Normal sensation over the deltoid and ability to flex at elbow.
Nvi
Specific Testing
(+) (-) AC Shear test on __ side(s).
(+) (-) Appley's Scratch test on __ side(s).
(+) (-) Anterior Apprehension test on __ side(s).
(+) (-) Codman's Drop Arm test on __ side(s).
(+) (-) Crank test on __ side(s).
(+) (-) Empty can test on __ side(s).
(+) (-) Lift off test on __ side(s).
(+) (-) Neer's Impingment test on __ side(s).
(+) (-) O'Brian's test on __ side(s).
(+) (-) Pectoral Contracture test on __ side(s).
(+) (-) Posterior Apprehension test on __ side(s).
(+) (-) Relocation test on __ side(s).
(+) (-) Supraspinatus test on __ side(s).
(+) (-) Sulcus test on __ side(s).
PE Elbow Pain 1
Gen: NAD, speaking full sentences
VS:WNL, afebrile, normotensive
Skin: PWD, intact
HEENT: NC, AT. PERRL,EOMI. trachea midline
Chest: CTA, good lung volume
Heart: RRR, No MRG, peripheral pulses are normal. Normal peripheral filling.
MSK: ***elbow is without obvious asymmetry or deformity when compared to other side. No obvious rash, redness, warmth, ecchymosis, obvious trauma abrasion, laceration or soft tissue swelling. No bony tenderness to palpation of the lateral or medial epicondyle, olecranon, or radial head. No epicondylar or axillary LAD. Normal flexion, extension, supination, pronation. Normal muscle strength. Intact motor and sensation of ulnar, median and radial nerves.
+/- Cozen’s test, Mill’s test , medial epicondylitis test
*** shoulder : Normal exam. No obvious trauma or deformity. No tenderness. Normal ROM without any pain.
*** wrist and hand : normal exam. No obvious trauma or deformity. No tenderness. Normal ROM without any pain.
Neuro: A&O x 4, good insight and judgement.
PE Wrist Carpal Tunnel 1
Gen: NAD, speaking full sentences
VSS, afebrile
Skin: PWD, intact
HEENT: AT, NC. PERRLA, EOMI. Trachea midline
Chest: CTA, good lung volume
Heart: RRR, no mrg
MSK: *** hand/wrist is with/without obvious asymmetry or deformity when compared to the other side . +/- swelling including surrounding anatomic snuff box. +/- erythema, atrophy, or obvious deformity. +/- surface trauma, open wounds, nail avulsion, tissue avulsion, partial or complete amputation, subungal hematoma, bony deformity. No focal fullness, throbbing, swelling of fingertip.
+/-PHALEN'S TEST with involvement of the first three digits and the radial half of the fourth digit.
+/- Tinel's sign Test.
Normal cascade of fingers. NT to palpation. NVI.
Normal flexion or extension of fingers/hands and wrists.
Full ROM of bilateral wrist and fingers.
Neuro: A&O x4, good insight and judgment. Normal bilateral upper extremity sensation and motor exam.
PE Hand pain 1
Gen: NAD, speaking full sentences
VSS, afebrile
Skin: PWD, intact
HEENT: AT, NC. PERRLA, EOMI. Trachea midline
Chest: CTA, good lung volume
Heart: RRR, no mrg
MSK: right/left hand: the *** hand is without obvious asymmetry or deformity when compared to the *** hand. No swelling, erythema, atrophy, or obvious deformity. No surface trauma, open wounds, nail avulsion, tissue avulsion, partial or complete amputation, subungal hematoma, bony deformity. Normal cascade of fingers. Normal flexion or extension of fingers. FDS an FDP intact against resistance. No focal fullness, throbbing, swelling of fingertip. NT to palpation. NVI
Neuro: A&O x4, good insight and judgment.
PE Eye Pain and Injury 1
Gen: NAD, speaking full sentences
VS: WNL, afebrile
Skin, PWD, intact
HEENT:
Head: NC, AT.
Eyes:
visual acuity:
Visual fields: full to confrontation
Periorbital: no warmth, erythema, tenderness or bony step off
Eyelids: No erythema, warmth, FB/lesion on lid eversion. CN 3 and 7 intact
Eyeballs. No enopthalmos or exophthalmos. No tenderness
Pupils: PERRLA, CN 2 and CN 3 intact
Corneas: grossly clear, no hyphema
Sclera: clear, not injected. no ciliary or limbic flush
Conjunctiva: No chemosis or subconjuctival hemorrhage
EOMI: intact, symmetrical gaze, no pain with movement. No nystagmus, ptosis or lid lag
Ears: canals and TM clear
nose/face: no congestion, drainage
Mouth/throat: MMM, pp clear
Neck: supple, No LAD.
Chest: CTA, good lung volume
Heart: RRR, No MRG
Msk: moves all extremities with good strength. NVI.
PE Peds simple
VITALS & BMI: Reviewed.
GEN: Normal general appearance. NAD.
HEENT
-Head: NC/AT.
-Eyes: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
-Ears: Normal external ears, normal TMs.
-Nose: Normal nares
-Mouth and Throat: MMM. Normal gums, mucosa, palate. Good dentition.
NECK: Supple, with no masses.
CV: RRR, no m/r/g.
LUNGS: CTAB, no w/r/c.
ABD: Soft, NT/ND, NBS, no masses or organomegaly.
GU: Normal genitalia.
SKIN: Warm & well perfused. No skin rashes or abnormal lesions.
MSK: Normal extremities & spine. No deformities. Normal gait. No clubbing, cyanosis, or edema.
NEURO: Normal muscle strength and tone. Normal motor function and balance. No focal deficits. ***Intact primitive reflexes.
GROWTH CHART: Following growth curve well in all parameters.
PE psychiatric evaluation GB
# Sensorium and cognitive function:
Orientation; oriented all spheres, disoriented (person, place,, time, situation)
Concentration: Intact, slightly distracted, impaired (mild, moderate, severe)
Memory: normal, impaired (immediate, recent, remote) and degree (mild, moderate, severe)
Intelligence: Above average, average, below average, borderline, mental retardation
# Mood and affect:
mood: normal, anxious, depressed, fearful, elevated, euphoric, angry
affect: appropriate, labile, expansive, blunted, flat
# Perception:
Hallucinations: none, auditory, visual, olfactory
Illusion: none, misidentification
# Thought Process:
Associations: Goal directed, blocking, circumstantial, tangential, loose, neologisms
Content-Delusions: None, persecution, somatic, broadcasting, grandiosity, religious, nihilistic, ideas of reference
Content-Preoccupations: None, obsessions, compulsions, phobias, sexual, suicidal, homicidal, depersonalization
Judgment: Intact, impaired (mild, moderate, severe)
# Alcohol and Drug Abuse:
Current alcohol use: None, social, abuse (occasional, binge pattern, daily)
Current illicit drug use: None, abuse (occasional episodic, daily), cannabis, cocaine, heroin, amphetamines, sedatives, hallucinogens, hypnotic, inhalants
History alcohol/drug abuse: None, none in past 6 months, none in past ___ years, continuous since ___.
PE Scabies
General Appearance: alert, in no acute distress, well hydrated
Skin: intensely pruritic eruption of small, excoriated, erythematous papules in following sites- the fingers, wrists, axillae, and waist
Nose: mucosa with inflammation and purulent nasal discharge.
Ears: TMs bilaterally intact, without bulging or erythema.
Eyes: normal conjunctiva, lids, PERRL
Throat: normal, without erythema, tonsillar inflammation or exudate. No posterior pharyngeal drainage
Lungs: clear to auscultation bilaterally. No wheezes or crackles.
Heart: RR; no murmur/click, S3/S4
BACK: no CVAT
ABDOMEN: Soft, non tender , not distended.
NEUROLOGICAL: Grossly intact
Physical Exam performed based on photos, echoes and visual inspection
and palpations under camera.
PE Sports CL'H
Has played ** for over 10 years. No significant accidents or health concerns, such as syncope, heat exhaustion or in the course of playing sports
Pt feels safe at home & among teammates. Has resources as needed for support.
No use of supplements to enhance or lose weight.
No family history of cardiac conditions.
Family history of cardiac condition includes mother/father/grandparent with ** onset at age **
GEN: alert, A&O x3, NAD. Answers questions appropriately, engaged in care.
HEAD: normocephalic, normal hair distribution over scalp.
EYES: Sclera white, conjunctiva non-injected, EOM intact. PERRL
NECK: Trachea is midline.
NEURO: CN II-XII intact; Muscle strength 5/5 throughout. Sensory: intact & equal bilaterally. Motor: good muscle tone & bulk. Reflexes: Triceps & patellar 2+ bilaterally. No nuchal rigidity. No focal neurological deficits.
CV: Audible S1/S2. no adventitious heart sounds.
PULM: CTA in upper & lower lobes bilat. BS vesicular. No cough, work of breathing, wheezes or crackles. Thorax symmetric with good expansion.
GI: BS auscultated in all quadrants. Abdomen soft, no distension, non-tender. No masses or organomegaly. Tympanic to percussion.
GU: No CVA tenderness
MSK: Non-ataxic gait. Normal strength & muscle tone. Full ROM of all extremities & joints. Patellar tracks properly without crepitus. Normal heel & toe walk. No scoliosis or deformities.
VASC: Capillary refill < 2 sec in fingers. No edema, ulceration or hair loss of extremities. No femoral or abdominal bruits. Radial & posterior tibial pulses are 2+ & symmetric
DERM: Skin warm & dry. No rash, ecchymosis or petechiae. Nails: no clubbing or cyanosis.
PSYCH: Mood & affect are appropriate. No signs of mental deficits.
Sport Physical Z02.5
Cleared for sports participation
- Recommendation made to follow up with cardiology work up within next 3 weeks.
- Snellen performed
- Tdap Given today
Health Education with respect to sports reviewed:
Use of protective gear, sunblock, hydration, teammate bullying, appropriate relationships with adults & coaches, avoidance of use of inappropriate supplements & performance enhancements, proper warm-up stretching, use of protective gear, understand signs and symptoms of dehydration, heat stroke, muscle strain, weakness, cramping, and will advocate for self if not feeling well.
Pt & parent verbalize understanding and agree with plan of care.
PE: scrotal pain/epididymitis
Gen: NAD, speaking full sentences
VSS, afebrile
Skin: PWD, no diaphoresis, cyanosis or pallor
HEENT:
Head: NC, AT
eyes: pupils PERRL and EOMI
Neck: supple, no LAD. no meningismus
Chest: CTA bilaterally, no rales, rhonchi or wheezing
Heart: RRR,
Abd: flat/obese without distention. No surface trauma, scars, incisions. +BS. NT. No guarding, rigidity to palpation. NT or mass to epigastric area. No HSM. Neg Murphy's sign. No periumbilical tenderness. No rebound in lower quadrants. NT over Mcburney's point. No suprapubic tenderness or distention. Good femoral pulses bilaterally. No CVAT. negative inguinal lymphadenopathy.
Male Reproductive: Testicles firm, non-tender, without masses or lesions. Descended bilaterally. No induration, erythema, but + /- R>L scrotal edema. Penis is/not circumcised, without lesions or discharge. No hernias palpated in the inguinal canals. positive cremasteric reflex and positive prehn sign. + tenderness of right/left epididymis
Neuro: A&O x 4, good insight and judgement.