A few random templates that might be of use
Adult and child URTI, complete physical, CVS exam, depression screen, ENT exam, physical exam, neuro exam
templates.txt
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*Adult URTI* URTI, *SYMPTOMS* Afebrile Ears NAD, Throat NAD, Snuffly Chest clear. Advised fluids, symptomatic treatment - Rv sos *Child URTI* URTI, *SYMPTOMS* Afebrile Ears NAD, Throat NAD, Snuffly Chest clear, no tachypnoea/recession, Abdo soft, non-tender. No rash no meningism. Advised - fluids, tylenol - Rv if any concerns *Complete Physiciam History Systems Enquiry - CVS/RS, GI, Endocrine, UG, NS all nil of note PMH - PUT ABOVE Family History- PUT ABOVE MedicationsPUT ABOVE OE - Looks well. No An/Cy/J/Nodes/Clubbing CVS - Pulse *80* reg, BP *put in Measurements* HS normal, no ankle oedema, JVP not elevated. Apex beat not displaced RS - RR No recession, Trachea central, PN Res all areas, BS vesic + nil Abdo - soft, non-tender, no masses, no LKKS, HOs intact BS normal NS - Cns II-XII intact. PERL, Discs flat. UL - Tone, Power, Co-ord - normal. Sensation grossly normal. LL - Tone, Power, Co-ord - normal. Sensation grossly normal. Plantars downgoing ENT - Ears NAD, Throat - NAD, Nasal mucosa - not inflamed *CVS exam* CVS-Pulse 80 reg, BP *put in Measurements* Peripheral pulses normal. JVP not elevated. Apex beat not displaced HS normal, no bruits, no peripheral oedema *Depression screen* Screen. In the last month: Lost interest/pleasure in things you usually enjoy? Felt sad, low, down, depressed or hopeless? If yes to either then use SIGECAPS - 5 for most days for at least 2 weeks for diagnosis of MDD (must include depressed mood or loss of interest) Sleep disturbance? Interest loss (reduced pleasure)? Guilt? Energy loss/fatigue? Concentration problems? Appetite change? Psychomotor changes? Suicidal thoughts? Consider using Patient Depression Questionnaire-9 or Mental Health Plan eform *ENT exam* ENT - Ears - NAD, Throat - NAD, Nasal mucosa - not inflamed *Physical exam* OE Looks well. No An/Cy/J/Nodes/Clubbing CVS - Pulse 80 reg, BP *put in Measurements* HS normal, no ankle oedema, JVP not elevated. Apex beat not displaced RS - RR No recession, Trachea central, PN Res all areas, BS vesic + nil Abdo - soft, non-tender, no masses, no LKKS, Hos intact BS normal NS - Cns II-XII intact. PERL, Discs flat. UL - Tone, Power, Co-ord - normal. Sensation grossly normal. LL - Tone, Power, Co-ord - normal. Sensation grossly normal. Plantars downgoing ENT - Ears - NAD, Throat - NAD, Nasal mucosa - not inflamed *Neuro exam* NS - CNs II-XII intact. PERL, Discs flat. UL - Tone, Power, Co-ord - normal. Sensation grossly normal. LL - Tone, Power, Co-ord - normal. Sensation grossly normal. Plantars downgoing.
