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PE (All normal - use macro)
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General (Normal)
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General (Normal)
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General (Abnormals)
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General Comments
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Head (Normal)
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Head (Normal)
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Head (Abnormals)
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Head Comments
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Eyes (Normal)
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Eyes (Normal)
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Both Eyes (Abnormals)
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Both Eyes Comments
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Right Eye (Abnormals)
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Right Eye Comments
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Left Eye (Abnormals)
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Left Eye Comments
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Ears (Normal)
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Ears (Normal)
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Ear (right/left)
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Ears: (Abnormals)
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Ears Comments
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Nose (Normal)
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Nose (Normal)
• • •
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Nose (Abnormals)
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Nose Comments
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Throat (Normal)
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Throat (Normal)
• • •
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Throat (Abnormals)
• • •
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Throat Comments
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Mouth (Abnormals)
• • •
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Mouth Comments
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Neck (Normal)
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Neck (Normal)
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Neck (Abnormals)
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Neck Comments
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Chest (Normal)
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Chest (Normal)
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Chest (Abnormals)
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Breath sounds
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in_____
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Chest Comments
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Heart (Normal)
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Heart (Normal)
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Heart (Abnormals)
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systolic/diastolic
• • •
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Grade
• • •
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please select
• • •
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please select
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pitting/non-pitting
• • •
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Heart Comments
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Abdomen (Normal)
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Abdomen (Normal)
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Abdomen (Abnormals)
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RLQ, LLQ,RUQ, LUQ
• • •
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tenderness in ______
• • •
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Abdomen Comments
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GU (Normal)
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GU (Normal)
• • •
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GU (Abnormals)
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GU Comments
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Musculoskeletal (Normal)
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Musculoskeletal (Normal)
• • •
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Musculoskeletal (Abnormals)
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Walks with limp/unable to bear weight
• • •
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If unable to bear weight, please select
• • •
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Musculoskeletal Comments
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Vascular (Normal)
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Vascular (Normal)
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Vascular (Abnormals)- edema
• • •
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dorsalis pedal pulse______
• • •
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left/right
• • •
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Skin with ____ discoloration
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Vascular Comments
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Skin___
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rash/lesion
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Description of the rash or lesion
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Location
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Skin Comments
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Psych (Abnormals)
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Psych Comments
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Neuro (Normal)
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Neuro (Normal)
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Neuro (Abnormals)
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if disoriented, to____
• • •
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please select
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on right/left
• • •
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cranial nerve exam abnormal (comments)
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Gait unsteady.
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Neuro Comments
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Default template below
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General WNL
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General Abnormal
• • •
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General Comments
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HEENT WNL
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HEENT Abnormal
• • •
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HEENT Comments
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Skin WNL
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Skin Lesion
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Skin Comments
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Skin Lesions
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Neck WNL
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Neck Abnormal
• • •
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Neck Comments
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Cardiovascular WNL
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Cardiovascular Abnormal
• • •
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Cardiovascular Comments
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Lungs WNL
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen WNL
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Abdomen Abnormal
• • •
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Abdomen Comments
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MSK WNL
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MSK Abnormal
• • •
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MSK Comments
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Breasts WNL
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Breasts Abnormal
• • •
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Breasts Comments
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Neuro WNL
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Neuro Abnormal
• • •
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Neuro Comments
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Extremities WNL
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Extrem Abnormal
• • •
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Extrem Comments
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