Document the Abnormal Thoracic Spine Exam Findings
Access the Thoracic Spine Exam - PE template.
In the Inspection panel, do the following:
Select whether the Posture is Symmetrical or Asymmetrical.
In the Posture section, click the text field to select a deformity from the Deformity list.
In the Posture section, click the Detail link and select an appropriate option from the Spine Inspection - PE window.
Enter the details of Atrophy, Crepitus, Apprehension, Ecchymosis, Maximum tenderness, and Skin/scars by selecting the desired option.
In the Range of Motion section, do the following:
In the Description section, select if the condition is Active or Passive.
In the Measurement section, document the details of the Thoracic, Shoulder, Elbow, and Wrist regions.
Document the desired details in the Range of Motion - Measurement and Range of Motion - Description sections.
Click Save & Close.
In the Strength panel, click the Strength Upper Extremity link, and then do the following:
In the Strength Upper Extremity - PE template, enter the findings in the Strength - Description and Strength - Measurement sections.
Click Save & Close.
The data is displayed in the respective fields in the Strength panel.
In the Neurovascular panel, do the following:
Click the Neurovascular Upper Extremity link.
Enter the findings in the Description, Measurement, Reflexes, Sensation, and Vascular sections.
Click Save & Close.
The data appears in the respective fields in the Neurovascular panel.
Click the Light Touch Upper Extremity link and enter the desired physical exam details.
Click Save & Close.
Click the Pin Prick Upper Extremity link and enter the desired physical exam details.
Click Save & Close.
In the Tests panel, do the following:
Click the Negative or Positive option for the Patrick's (Faber) right and Patrick's (Faber) left fields.
Click the Femoral stretch right and Femoral stretch left fields and select an option from the corresponding Ort Femoral str lists.
Click the Straight leg raise right and Straight leg raise left fields and select an option from the corresponding SLR lists.
In the Test panel, in the Additional Exam and Findings section, select the desired Exam, Findings and Additional Findings details by clicking the respective fields.
To add the Exam, Findings and Additional Findings, click Add.
To modify the Exam, Findings and Additional Findings, click Update.
To clear the selected Exam, Findings and Additional Findings, click Clear.
To remove the existing record from the grid, select the entry from the grid, and then click Remove.
Note: You can configure the additional exam findings using the ortho_additional_exam and ortho_additional_findingCustom DB Picklists template.
In the Comments field, enter your comments, and then click OK.
