Dr Dinosaur,
HEENT: extraocular muscles intact, pupils equal round and reactive to light, TM's canals unremarkable, nares mucosa within normal limits, oral mucosa within normal limits
Neck: there is no thyromegaly, adenopathy or bruits
Cor: regular rate and rhythm without S3 S4 or murmur
Lungs: clear to auscultation and percussion without any sign of wheezing or crackles
Breasts: there is no dimpling or masses
GI: no hepatosplenomegaly, no rebound or guarding, bowel sounds are present, no evidence of distention
GU: the external genitalia is normal and the cervix is within normal limits and nontender, on bimanual exam there are no uterine or adnexal masses
Rectal: the stool is brown, guaiac negative, there are no rectal masses
Ext: there is no cyanosis, clubbing or edema
Neuro: cranial nerves two through 12 are intact, motor grossly nonfocal, sensory no obvious deficits, reflexes intact
Skin: no rashes, ulcers, or suspicious skin lesions
So what I do to my female template is if there is 3+ edema, I left click on the words just to the right of Ext: and drag my mouse across till it all lights up blue and then delete the entire section--there is no cyanosis, clubbing or edema, and then place my mouse where the t was in there and with voice transcribe three plus edema, and then move the template to the physical exam section
It really works nice, because most patients have many more normals than abnormals and you don't have to keep redictating the same female exam every time.
Now if I don't do a pelvic or rectal, I just delete those 2 sections, and hit the delete button after putting the cursor on the n of distention at the end of the GI: section so the Ext: section abuts up against the GI: section so the note looks nice.
I hope this helps.
