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@@ -0,0 +1,1963 @@
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+{
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+ "section": "exam-gu-rectal-detail",
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+ "templateSet": "Pessary Care",
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+ "templates": [
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+ {
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+ "text": "1-Click normal exams",
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+ "template": "{children}",
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+ "children": [
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+ {
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+ "text": "GEN: NAD",
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+ "template": "GEN: NAD"
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+ },
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+ {
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+ "text": "HEENT: NCAT",
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+ "template": "HEENT: normocephalic, atraumatic, no lesions noted"
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+ },
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+ {
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+ "text": "NECK: supple, -thyromeg\/mass\/palp lymphadenopath",
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+ "template": "NECK: supple, without thyromegaly, masses, or palpable lymphadenopathy"
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+ },
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+ {
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+ "text": "CV: RRR no murmurs, gallops, or rubs",
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+ "template": "CV: RRR without murmurs, gallops, or rub"
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+ },
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+ {
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+ "text": "RESP: CTA no RRW",
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+ "template": "RESP: clear to auscultation anteriorly and posteriorly without rales, rhonchi, or\n wheezes\n "
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+ },
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+ {
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+ "text": "ABDOMEN: flat, ND, No HSM\/masses\/tenderness",
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+ "template": "GI: abdomen flat, nondistended, without hepatosplenomegaly, masses, or tenderness\n "
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+ },
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+ {
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+ "text": "BACK: no CVA tenderness",
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+ "template": "MUSC\/SKEL: no CVA tenderness"
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+ },
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+ {
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+ "text": "BLADDER: nondistended, no masses",
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+ "template": "GU\/RECTAL: bladder nondistended, no masses"
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+ },
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+ {
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+ "text": "GU: no suprapubic tenderness",
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+ "template": "GU\/RECTAL: no suprapubic tenderness"
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+ },
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+ {
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+ "text": "GU: no urethral discharge",
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+ "template": "GU\/RECTAL: no urethral discharge"
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+ },
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+ {
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+ "text": "PELVIC: NL vag tone\/-bleed\/erosion\/+pessary",
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+ "template": "GU\/RECTAL: NL vaginal tone, pessary present, removed, cleaned, and replaced, no\n erosion or bleeding noted\n "
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+ },
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+ {
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+ "text": "RECTAL: normal tone, no masses",
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+ "template": "GU\/RECTAL: rectal: normal tone, no masses"
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+ },
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+ {
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+ "text": "MUSC: strength intact BL U and LE",
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+ "template": "MUSC\/SKEL: strength intact BL upper and lower extremities"
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+ },
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+ {
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+ "text": "EXT: no edema, erythema or cords",
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+ "template": "EXT: extremities nontender, no edema, erythema, or cords"
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+ },
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+ {
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+ "text": "NEURO: patellar\/ankle DTRs NL BL",
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+ "template": "NEURO: patellar\/ankle DTRs NL BL"
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+ },
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+ {
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+ "text": "NEURO: distal sensation intact BL",
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+ "template": "NEURO: distal sensation intact BL"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Pertinent findings",
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+ "template": "{children}",
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+ "children": [
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+ {
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+ "text": "Gen",
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+ "template": "GEN: {children}",
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+ "children": [
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+ {
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+ "text": "WDWN",
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+ "template": "WDWN"
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+ },
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+ {
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+ "text": "NAD",
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+ "template": "NAD"
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+ },
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+ {
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+ "text": "overweight",
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+ "template": "overweight",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "obese",
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+ "template": "obese",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "morbidly obese",
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+ "template": "morbidly obese",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "mildly distressed",
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+ "template": "mildly distressed"
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+ },
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+ {
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+ "text": "moderately distressed",
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+ "template": "moderately distressed"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "HEENT",
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+ "template": "HEENT: {children}",
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+ "children": [
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+ {
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+ "text": "head atraumatic",
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+ "template": "head atraumatic"
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+ },
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+ {
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+ "text": "hearing grossly intact",
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+ "template": "hearing grossly intact"
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+ },
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+ {
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+ "text": "EOMI",
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+ "template": "EOMI",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "scleral icterus",
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+ "template": "scleral icterus",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "tongue lesions",
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+ "template": "tongue lesions",
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+ "type": "plus-minus"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Neck",
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+ "template": "NECK: {children}",
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+ "children": [
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+ {
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+ "text": "supple, soft, nontender to palpation",
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+ "template": "supple, soft, nontender to palpation"
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+ },
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+ {
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+ "text": "no thyromegaly",
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+ "template": "no thyromegaly"
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+ },
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+ {
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+ "text": "no cervical lymphadenopathy appreciated",
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+ "template": "no cervical lymphadenopathy appreciated"
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+ },
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+ {
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+ "text": "symmetric thyromegaly",
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+ "template": "symmetric thyromegaly is noted"
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+ },
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+ {
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+ "text": "L thyroid mass\/enlargement",
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+ "template": "left thyroid mass\/enlargement"
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+ },
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+ {
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+ "text": "R thyroid mass\/enlargement",
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+ "template": "right thyroid mass\/enlargement"
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+ },
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+ {
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+ "text": "nodular goiter",
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+ "template": "nodular goiter"
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+ },
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+ {
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+ "text": "shotty lymph nodes are palpable",
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+ "template": "shotty lymph nodes are palpable"
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+ },
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+ {
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+ "text": "R lymphadenopathy",
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+ "template": "right lymphadenopathy is noted"
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+ },
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+ {
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+ "text": "L lymphadenopathy",
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+ "template": "left lymphadenopathy is noted"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Respiratory",
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+ "template": "RESP: {children}",
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+ "children": [
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+ {
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+ "text": "lungs clear to auscultation bilaterally",
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+ "template": "lungs clear to auscultation bilaterally"
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+ },
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+ {
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+ "text": "scattered wheezes",
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+ "template": "scattered wheezes are noted"
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+ },
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+ {
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+ "text": "rales at bases bilateral",
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+ "template": "rales are noted at bases bilaterally"
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+ },
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+ {
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+ "text": "rales along R lung field",
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+ "template": "rales noted along right lung field"
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+ },
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+ {
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+ "text": "rales along L lung field",
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+ "template": "rales noted along left lung field"
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+ },
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+ {
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+ "text": "E to A changes in lung field",
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+ "template": "E to A changes are noted in lung field"
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+ },
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+ {
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+ "text": "rhonchi",
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+ "template": "rhonchi",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "labored breathing",
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+ "template": "labored breathing",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "accessory muscle use",
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+ "template": "accessory muscle use",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "rib retractions",
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+ "template": "rib retractions",
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+ "type": "plus-minus"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Cardiovascular",
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+ "template": "CV: {children}",
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+ "children": [
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+ {
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+ "text": "regular rate and rhythm",
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+ "template": "regular rate and rhythm"
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+ },
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+ {
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+ "text": "no murmurs, gallops, or rubs",
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+ "template": "no murmurs, gallops, or rubs"
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+ },
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+ {
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+ "text": "regularly irregular rhythm",
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+ "template": "regularly irregular rhythm"
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+ },
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+ {
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+ "text": "irregularly irregular rhythm",
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+ "template": "irregularly irregular rhythm"
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+ },
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+ {
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+ "text": "S3 gallop",
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+ "template": "S3 gallop is noted"
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+ },
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+ {
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+ "text": "S4 gallop",
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+ "template": "S4 gallop is noted"
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+ },
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+ {
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+ "text": "systolic murmur",
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+ "template": "systolic murmur",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "diastolic murmur",
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+ "template": "diastolic murmur",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "friction rub",
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+ "template": "friction rub",
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+ "type": "plus-minus"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Abdomen",
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+ "template": "GI: abdominal exam: {children}",
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+ "children": [
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+ {
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+ "text": "distended",
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+ "template": "distended",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "flat",
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+ "template": "flat",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "obese",
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+ "template": "obese",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "bowel sounds intact",
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+ "template": "bowel sounds intact",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "bowel sounds diminished",
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+ "template": "bowel sounds diminished",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "bowel sounds absent",
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+ "template": "bowel sounds absent",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "enlarged abdominal aorta",
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+ "template": "enlarged abdominal aorta",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "abdominal aortic bruit",
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+ "template": "abdominal aortic bruit",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "tenderness with palpation",
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+ "template": "tenderness with palpation",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "rebound",
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+ "template": "rebound",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "guarding",
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+ "template": "guarding",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "rigidity",
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+ "template": "rigidity",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "mass",
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+ "template": "mass",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "hepatomegaly",
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+ "template": "hepatomegaly",
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+ "type": "plus-minus"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Back",
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+ "template": "MUSC\/SKEL: back: {children}",
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+ "children": [
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+ {
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+ "text": "R CVA tenderness",
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+ "template": "R CVA tenderness",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "L CVA tenderness",
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+ "template": "L CVA tenderness",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "BL CVA tenderness",
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+ "template": "BL CVA tenderness",
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+ "type": "plus-minus"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Bladder",
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+ "template": "GU\/RECTAL: bladder: {children}",
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+ "children": [
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+ {
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+ "text": "normal",
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+ "template": "(+) normal"
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+ },
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+ {
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+ "text": "tender",
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+ "template": "tender",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "masses",
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+ "template": "masses",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "distended",
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+ "template": "distended",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "cystocele",
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+ "template": "cystocele",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "suprapubic tenderness",
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+ "template": "suprapubic tenderness",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "bladder stress test",
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+ "template": "bladder stress test",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "bladder distended",
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+ "template": "bladder distended",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "leak with Valsalva, supine",
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+ "template": "leak with Valsalva, supine",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "leak with Valsalva, upright",
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+ "template": "leak with Valsalva, upright",
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+ "type": "plus-minus"
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+ }
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+ ]
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+ },
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+ {
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+ "text": "Urethra",
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+ "template": "GU\/RECTAL: urethra: {children}",
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+ "children": [
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+ {
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+ "text": "hypermobility",
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+ "template": "hypermobility",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "supine leak test",
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+ "template": "supine leak test",
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+ "type": "plus-minus"
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+ },
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+ {
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+ "text": "meatal caruncle",
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+ "template": "meatal caruncle",
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|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "prolapsed mucosa",
|
|
|
+ "template": "prolapsed mucosa",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vulva",
|
|
|
+ "template": "GU\/RECTAL: vulva {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "normal appearance w\/o rash\/lesions\/ulcer",
|
|
|
+ "template": "normal in appearance without rashes, lesions or ulcerations"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "condyloma",
|
|
|
+ "template": "condyloma",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "white lesions",
|
|
|
+ "template": "white lesions",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pigmented lesions",
|
|
|
+ "template": "pigmented lesions",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "loss of pigmentation",
|
|
|
+ "template": "loss of pigmentation",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "ulcerations",
|
|
|
+ "template": "ulcerations",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "cracking",
|
|
|
+ "template": "cracking",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "atrophy",
|
|
|
+ "template": "atrophy",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina",
|
|
|
+ "template": "GU\/RECTAL: Vagina: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "NL appearance",
|
|
|
+ "template": "NL appearance"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "NL pelvic support",
|
|
|
+ "template": "NL pelvic support"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "vaginal tone decreased",
|
|
|
+ "template": "vaginal tone decreased",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "vaginal prolapse",
|
|
|
+ "template": "vaginal prolapse",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pale vaginal mucosa",
|
|
|
+ "template": "pale vaginal mucosa",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "atrophy",
|
|
|
+ "template": "atrophy",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "discharge",
|
|
|
+ "template": "discharge",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "lesions",
|
|
|
+ "template": "lesions",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "bleeding",
|
|
|
+ "template": "bleeding",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "stenosis present",
|
|
|
+ "template": "stenosis present"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pessary present",
|
|
|
+ "template": "pessary present, removed, cleaned, and replaced"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pessary present, removed, not replaced due to erosion",
|
|
|
+ "template": "pessary present, removed, not replaced due to erosion"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "granulation tissue",
|
|
|
+ "template": "granulation tissue",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "erosion",
|
|
|
+ "template": "erosion",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Cervix",
|
|
|
+ "template": "GU\/RECTAL: cervix: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "NL appearance",
|
|
|
+ "template": "NL appearance"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "midline",
|
|
|
+ "template": "midline"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "lesions",
|
|
|
+ "template": "lesions",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "discharge",
|
|
|
+ "template": "discharge",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "bleeding",
|
|
|
+ "template": "bleeding",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "specimens obtained for smear",
|
|
|
+ "template": "specimens obtained for smear",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "specimens obtained for culture",
|
|
|
+ "template": "specimens obtained for culture",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p surgical removal",
|
|
|
+ "template": "s\/p surgical removal"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Uterus",
|
|
|
+ "template": "GU\/RECTAL: uterus: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "no abnormalities",
|
|
|
+ "template": "no abnormalities"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "NL position",
|
|
|
+ "template": "NL position"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "NL mobility",
|
|
|
+ "template": "NL mobility"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "NL contour",
|
|
|
+ "template": "NL contour"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "enlarged",
|
|
|
+ "template": "enlarged",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "prolapse",
|
|
|
+ "template": "prolapse",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "tender",
|
|
|
+ "template": "tender",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "surgically absent",
|
|
|
+ "template": "surgically absent"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "irregular contour",
|
|
|
+ "template": "irregular contour"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "reduced mobility",
|
|
|
+ "template": "reduced mobility"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "enlarged consistent with fibroids",
|
|
|
+ "template": "enlarged consistent with fibroids"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "size consistent with 12-14 weeks",
|
|
|
+ "template": "size consistent with 12-14 weeks"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "size consistent with 16-18 weeks",
|
|
|
+ "template": "size consistent with 16-18 weeks"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "size consistent with 20-22 weeks",
|
|
|
+ "template": "size consistent with 20-22 weeks"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "size greater than 22 weeks",
|
|
|
+ "template": "size greater than 22 weeks"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Adnexa, R",
|
|
|
+ "template": "GU\/RECTAL: adnexa R: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "no abnormalities",
|
|
|
+ "template": "no abnormalities"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "tender",
|
|
|
+ "template": "tender",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "masses",
|
|
|
+ "template": "masses",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "nodules",
|
|
|
+ "template": "nodules",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "enlarged",
|
|
|
+ "template": "enlarged",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p salpingectomy",
|
|
|
+ "template": "s\/p salpingectomy"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p oophorectomy",
|
|
|
+ "template": "s\/p oophorectomy"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p salpingo-oophorectomy",
|
|
|
+ "template": "s\/p salpingo-oophorectomy"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Adnexa, L",
|
|
|
+ "template": "GU\/RECTAL: adnexa L: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "no abnormalities",
|
|
|
+ "template": "no abnormalities"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "tender",
|
|
|
+ "template": "tender",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "masses",
|
|
|
+ "template": "masses",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "nodules",
|
|
|
+ "template": "nodules",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "enlarged",
|
|
|
+ "template": "enlarged",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p salpingectomy",
|
|
|
+ "template": "s\/p salpingectomy"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p oophorectomy",
|
|
|
+ "template": "s\/p oophorectomy"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p salpingo-oophorectomy",
|
|
|
+ "template": "s\/p salpingo-oophorectomy"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Adnexae BL",
|
|
|
+ "template": "GU\/RECTAL: adnexae BL: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "no abnormalities",
|
|
|
+ "template": "no abnormalities"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "tender",
|
|
|
+ "template": "tender",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "masses",
|
|
|
+ "template": "masses",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "nodules",
|
|
|
+ "template": "nodules",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "enlarged",
|
|
|
+ "template": "enlarged",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p salpingectomy",
|
|
|
+ "template": "s\/p salpingectomy"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p oophorectomy",
|
|
|
+ "template": "s\/p oophorectomy"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "s\/p salpingo-oophorectomy",
|
|
|
+ "template": "s\/p salpingo-oophorectomy"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Anorectal area",
|
|
|
+ "template": "GU\/RECTAL: anus\/rectum: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "no abnormalities",
|
|
|
+ "template": "no abnormalities"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "NL tone",
|
|
|
+ "template": "NL tone"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "rectal tone decreased",
|
|
|
+ "template": "rectal tone decreased",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "hard stool in vault",
|
|
|
+ "template": "hard stool in vault",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "perianal lesions",
|
|
|
+ "template": "perianal lesions",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "external hemorrhoids",
|
|
|
+ "template": "external hemorrhoids",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "internal hemorrhoids",
|
|
|
+ "template": "internal hemorrhoids",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "rectocele",
|
|
|
+ "template": "rectocele",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "masses",
|
|
|
+ "template": "masses",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "stool positive for occult blood",
|
|
|
+ "template": "stool positive for occult blood"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "stool negative for occult blood",
|
|
|
+ "template": "stool negative for occult blood"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "gross blood noted on DRE",
|
|
|
+ "template": "gross blood noted on DRE"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "rectal mucosal prolapse",
|
|
|
+ "template": "rectal mucosal prolapse"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: Point Aa",
|
|
|
+ "template": "GU\/RECTAL: vagina point Aa: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "-3",
|
|
|
+ "template": "-3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-2",
|
|
|
+ "template": "-2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-1",
|
|
|
+ "template": "-1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1",
|
|
|
+ "template": "+1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2",
|
|
|
+ "template": "+2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3",
|
|
|
+ "template": "+3"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: Point Ba",
|
|
|
+ "template": "GU\/RECTAL: vagina point Ba: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "-8",
|
|
|
+ "template": "-8"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-7",
|
|
|
+ "template": "-7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-6",
|
|
|
+ "template": "-6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-5",
|
|
|
+ "template": "-5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-4",
|
|
|
+ "template": "-4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-3",
|
|
|
+ "template": "-3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-2",
|
|
|
+ "template": "-2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-1",
|
|
|
+ "template": "-1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1",
|
|
|
+ "template": "+1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2",
|
|
|
+ "template": "+2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3",
|
|
|
+ "template": "+3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4",
|
|
|
+ "template": "+4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5",
|
|
|
+ "template": "+5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+6",
|
|
|
+ "template": "+6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+7",
|
|
|
+ "template": "+7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+8",
|
|
|
+ "template": "+8"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: Point C",
|
|
|
+ "template": "GU\/RECTAL: vagina point C: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "-8",
|
|
|
+ "template": "-8"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-7",
|
|
|
+ "template": "-7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-6",
|
|
|
+ "template": "-6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-5",
|
|
|
+ "template": "-5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-4",
|
|
|
+ "template": "-4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-3",
|
|
|
+ "template": "-3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-2",
|
|
|
+ "template": "-2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-1",
|
|
|
+ "template": "-1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1",
|
|
|
+ "template": "+1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2",
|
|
|
+ "template": "+2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3",
|
|
|
+ "template": "+3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4",
|
|
|
+ "template": "+4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5",
|
|
|
+ "template": "+5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+6",
|
|
|
+ "template": "+6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+7",
|
|
|
+ "template": "+7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+8",
|
|
|
+ "template": "+8"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: Point D",
|
|
|
+ "template": "GU\/RECTAL: vagina point D: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "absent",
|
|
|
+ "template": "absent"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-9",
|
|
|
+ "template": "-9"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-8",
|
|
|
+ "template": "-8"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-7",
|
|
|
+ "template": "-7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-6",
|
|
|
+ "template": "-6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-5",
|
|
|
+ "template": "-5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-4",
|
|
|
+ "template": "-4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-3",
|
|
|
+ "template": "-3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-2",
|
|
|
+ "template": "-2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-1",
|
|
|
+ "template": "-1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1",
|
|
|
+ "template": "+1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2",
|
|
|
+ "template": "+2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3",
|
|
|
+ "template": "+3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4",
|
|
|
+ "template": "+4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5",
|
|
|
+ "template": "+5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+6",
|
|
|
+ "template": "+6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+7",
|
|
|
+ "template": "+7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+8",
|
|
|
+ "template": "+8"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+9",
|
|
|
+ "template": "+9"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: Point Ap",
|
|
|
+ "template": "GU\/RECTAL: vagina point Ap: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "-3",
|
|
|
+ "template": "-3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-2",
|
|
|
+ "template": "-2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-1",
|
|
|
+ "template": "-1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1",
|
|
|
+ "template": "+1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2",
|
|
|
+ "template": "+2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3",
|
|
|
+ "template": "+3"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: Point Bp",
|
|
|
+ "template": "GU\/RECTAL: vagina point Bp: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "-6",
|
|
|
+ "template": "-6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-5",
|
|
|
+ "template": "-5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-4",
|
|
|
+ "template": "-4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-3",
|
|
|
+ "template": "-3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-2",
|
|
|
+ "template": "-2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "-1",
|
|
|
+ "template": "-1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1",
|
|
|
+ "template": "+1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2",
|
|
|
+ "template": "+2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3",
|
|
|
+ "template": "+3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4",
|
|
|
+ "template": "+4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5",
|
|
|
+ "template": "+5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+6",
|
|
|
+ "template": "+6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+7",
|
|
|
+ "template": "+7"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: GH",
|
|
|
+ "template": "GU\/RECTAL: vagina GH: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "0.5",
|
|
|
+ "template": "0.5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "1",
|
|
|
+ "template": "1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "2",
|
|
|
+ "template": "2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "3",
|
|
|
+ "template": "3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "4",
|
|
|
+ "template": "4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "5",
|
|
|
+ "template": "5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "6",
|
|
|
+ "template": "6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "7",
|
|
|
+ "template": "7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "8",
|
|
|
+ "template": "8"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: PB",
|
|
|
+ "template": "GU\/RECTAL: vagina PB: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "0",
|
|
|
+ "template": "0"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "1",
|
|
|
+ "template": "1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "2",
|
|
|
+ "template": "2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "3",
|
|
|
+ "template": "3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "4",
|
|
|
+ "template": "4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "5",
|
|
|
+ "template": "5"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Vagina: TVL",
|
|
|
+ "template": "GU\/RECTAL: vagina TVL: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "0.5",
|
|
|
+ "template": "0.5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "1",
|
|
|
+ "template": "1"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "2",
|
|
|
+ "template": "2"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "3",
|
|
|
+ "template": "3"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "4",
|
|
|
+ "template": "4"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "5",
|
|
|
+ "template": "5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "6",
|
|
|
+ "template": "6"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "7",
|
|
|
+ "template": "7"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "8",
|
|
|
+ "template": "8"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "9",
|
|
|
+ "template": "9"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "10",
|
|
|
+ "template": "10"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Extremities",
|
|
|
+ "template": "EXT: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "nontender with no edema, erythema or cords",
|
|
|
+ "template": "nontender with no edema, erythema or cords"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pitting edema in lower extremities",
|
|
|
+ "template": "pitting edema in lower extremities",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "RLE pitting edema",
|
|
|
+ "template": "RLE pitting edema",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "LLE pitting edema",
|
|
|
+ "template": "LLE pitting edema",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "normal strength and tone",
|
|
|
+ "template": "normal strength and tone"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "muscle wasting",
|
|
|
+ "template": "muscle wasting",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "peripheral pulses intact",
|
|
|
+ "template": "peripheral pulses intact"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "peripheral pulses decreased",
|
|
|
+ "template": "peripheral pulses decreased"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "peripheral pulses not palpable",
|
|
|
+ "template": "peripheral pulses not palpable"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Abdominal musculoskeletal tenderness",
|
|
|
+ "template": "MUSC\/SKEL: abdominal musculoskeletal tenderness: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "no tenderness noted",
|
|
|
+ "template": "no tenderness of abdominal wall musculature noted"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "iliopsoas tenderness R",
|
|
|
+ "template": "iliopsoas tenderness R",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "iliopsoas tenderness L",
|
|
|
+ "template": "iliopsoas tenderness L",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "rectus abdominis tenderness R",
|
|
|
+ "template": "rectus abdominis tenderness right",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "rectus abdominis tenderness L",
|
|
|
+ "template": "rectus abdominis tenderness left",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "L lateral oblique tenderness",
|
|
|
+ "template": "left lateral oblique tenderness",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "R lateral oblique tenderness",
|
|
|
+ "template": "right lateral oblique tenderness",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Pelvic floor muscle spasm",
|
|
|
+ "template": "MUSC\/SKEL: pelvic floor muscle spasm {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "puborectalis muscle R",
|
|
|
+ "template": "puborectalis muscle R",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "puborectalis muscle L",
|
|
|
+ "template": "puborectalis muscle L",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pubococcygeus muscle R",
|
|
|
+ "template": "pubococcygeus muscle R",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "pubococcygeus muscle L",
|
|
|
+ "template": "pubococcygeus muscle L",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "obturator internus muscle R",
|
|
|
+ "template": "obturator internus muscle R",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "obturator internus muscle L",
|
|
|
+ "template": "obturator internus muscle L",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "coccygeus muscle R",
|
|
|
+ "template": "coccygeus muscle R",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "coccygeus muscle L",
|
|
|
+ "template": "coccygeus muscle L",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "bulbocavernosus\/perineal muscle R",
|
|
|
+ "template": "bulbocavernosus\/perineal muscle R",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "bulbocavernosus\/perineal muscle L",
|
|
|
+ "template": "bulbocavernosus\/perineal muscle L",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "no pelvic floor musculoskeletal tenderness",
|
|
|
+ "template": "no musculoskeletal tenderness is identified in the pelvic floor"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Strength, RLE",
|
|
|
+ "template": "MUSC\/SKEL: RLE {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "weakness",
|
|
|
+ "template": "weakness",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1\/5",
|
|
|
+ "template": "+1\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2\/5",
|
|
|
+ "template": "+2\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3\/5",
|
|
|
+ "template": "+3\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4\/5",
|
|
|
+ "template": "+4\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5\/5",
|
|
|
+ "template": "+5\/5"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Strength, LLE",
|
|
|
+ "template": "MUSC\/SKEL: LLE {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "weakness",
|
|
|
+ "template": "weakness",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1\/5",
|
|
|
+ "template": "+1\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2\/5",
|
|
|
+ "template": "+2\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3\/5",
|
|
|
+ "template": "+3\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4\/5",
|
|
|
+ "template": "+4\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5\/5",
|
|
|
+ "template": "+5\/5"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Strength, BL LE",
|
|
|
+ "template": "MUSC\/SKEL: BL LE {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "LE weakness",
|
|
|
+ "template": "LE weakness",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+1\/5",
|
|
|
+ "template": "+1\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+2\/5",
|
|
|
+ "template": "+2\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+3\/5",
|
|
|
+ "template": "+3\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+4\/5",
|
|
|
+ "template": "+4\/5"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "+5\/5",
|
|
|
+ "template": "+5\/5"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro: General",
|
|
|
+ "template": "NEURO: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "alert and oriented to time, place and person",
|
|
|
+ "template": "alert and oriented to time, place and person"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "appears disoriented",
|
|
|
+ "template": "appears disoriented"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "cognitive impairment is noted",
|
|
|
+ "template": "cognitive impairment is noted"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro, R",
|
|
|
+ "template": "NEURO: R {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "NL gait",
|
|
|
+ "template": "(+) NL gait"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "gait ataxia",
|
|
|
+ "template": "gait ataxia",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "foot drop",
|
|
|
+ "template": "foot drop",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "LE spasticity",
|
|
|
+ "template": "LE spasticity",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "LE sensation decreased",
|
|
|
+ "template": "LE sensation decreased",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR not elicited",
|
|
|
+ "template": "patellar DTR not elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +1",
|
|
|
+ "template": "patellar DTR +1",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +2",
|
|
|
+ "template": "patellar DTR +2",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +3",
|
|
|
+ "template": "patellar DTR +3",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +4",
|
|
|
+ "template": "patellar DTR +4",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR not elicited",
|
|
|
+ "template": "Achilles DTR not elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +1",
|
|
|
+ "template": "Achilles DTR +1",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +2",
|
|
|
+ "template": "Achilles DTR +2",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +3",
|
|
|
+ "template": "Achilles DTR +3",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +4",
|
|
|
+ "template": "Achilles DTR +4",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Babinski elicited",
|
|
|
+ "template": "Babinski elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro, L",
|
|
|
+ "template": "NEURO: L {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "NL gait",
|
|
|
+ "template": "(+) NL gait"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "gait ataxia",
|
|
|
+ "template": "gait ataxia",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "foot drop",
|
|
|
+ "template": "foot drop",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "LE spasticity",
|
|
|
+ "template": "LE spasticity",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "LE sensation decreased",
|
|
|
+ "template": "LE sensation decreased",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR not elicited",
|
|
|
+ "template": "patellar DTR not elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +1",
|
|
|
+ "template": "patellar DTR +1",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +2",
|
|
|
+ "template": "patellar DTR +2",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +3",
|
|
|
+ "template": "patellar DTR +3",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +4",
|
|
|
+ "template": "patellar DTR +4",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR not elicited",
|
|
|
+ "template": "Achilles DTR not elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +1",
|
|
|
+ "template": "Achilles DTR +1",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +2",
|
|
|
+ "template": "Achilles DTR +2",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +3",
|
|
|
+ "template": "Achilles DTR +3",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +4",
|
|
|
+ "template": "Achilles DTR +4",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Babinski elicited",
|
|
|
+ "template": "Babinski elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro, BL",
|
|
|
+ "template": "NEURO: BL {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "NL gait",
|
|
|
+ "template": "(+) NL gait"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "gait ataxia",
|
|
|
+ "template": "gait ataxia",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "foot drop",
|
|
|
+ "template": "foot drop",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "LE spasticity",
|
|
|
+ "template": "LE spasticity",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased LE sensation",
|
|
|
+ "template": "decreased LE sensation",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR not elicited",
|
|
|
+ "template": "patellar DTR not elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +1",
|
|
|
+ "template": "patellar DTR +1",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +2",
|
|
|
+ "template": "patellar DTR +2",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +3",
|
|
|
+ "template": "patellar DTR +3",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "patellar DTR +4",
|
|
|
+ "template": "patellar DTR +4",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR not elicited",
|
|
|
+ "template": "Achilles DTR not elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +1",
|
|
|
+ "template": "Achilles DTR +1",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +2",
|
|
|
+ "template": "Achilles DTR +2",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +3",
|
|
|
+ "template": "Achilles DTR +3",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Achilles DTR +4",
|
|
|
+ "template": "Achilles DTR +4",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Babinski elicited",
|
|
|
+ "template": "Babinski elicited",
|
|
|
+ "type": "plus-minus"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro: vulvar sensation",
|
|
|
+ "template": "NEURO: vulvar sensation {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "intact over vulva and inner thighs",
|
|
|
+ "template": "intact over vulva and inner thighs"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased over L anterior vulva",
|
|
|
+ "template": "decreased over left anterior vulva"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased over R anterior vulva",
|
|
|
+ "template": "decreased over right anterior vulva"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased over L inner thigh",
|
|
|
+ "template": "decreased over left inner thigh"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased over R inner thigh",
|
|
|
+ "template": "decreased over right inner thigh"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased over L perineum\/perianal skin",
|
|
|
+ "template": "decreased over left perineum\/perianal skin"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "decreased over R perineum\/perianal skin",
|
|
|
+ "template": "decreased over right perineum\/perianal skin"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro: Bulbocavernosus reflex",
|
|
|
+ "template": "NEURO: Bulbocavernosus reflex {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "present and normal",
|
|
|
+ "template": "present and normal"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "present and prolonged",
|
|
|
+ "template": "present and prolonged"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "absent",
|
|
|
+ "template": "absent"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Neuro: anal wink reflex",
|
|
|
+ "template": "NEURO: anal wink reflex",
|
|
|
+ "type": "plus-minus"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "Psych",
|
|
|
+ "template": "PSYCH: {children}",
|
|
|
+ "children": [
|
|
|
+ {
|
|
|
+ "text": "mood is appropriate to situation",
|
|
|
+ "template": "mood is appropriate to situation"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "normal affect",
|
|
|
+ "template": "normal affect"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "affect is depressed",
|
|
|
+ "template": "affect is depressed"
|
|
|
+ },
|
|
|
+ {
|
|
|
+ "text": "affect is agitated",
|
|
|
+ "template": "affect is agitated"
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ }
|
|
|
+ ]
|
|
|
+ }
|
|
|
+ ]
|
|
|
+}
|