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/or Femoral stretch left fields and select an option from the corresponding Ort Femoral str lists.
- Click the Straight leg raise right and/or 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_finding Custom DB Picklists template.
- In the Comments field, enter your comments, and then click OK.
The data appears on the Physical Exam grid.
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