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Add graphical CCS physical examination

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hz
2026-08-10 03:27:45 -05:00
parent 579e1e9be4
commit 07516784d2
5 changed files with 306 additions and 15 deletions
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content/ccs/duodenal-ulcer-office-001.json
+22 -2
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@@ -110,7 +110,20 @@
}
},
"allowedLocations": ["office"],
"exams": [],
"exams": [
{ "code": "physical_appearance", "name": "Physical Appearance", "durationMinutes": 1, "finding": "The patient is alert, cooperative, and in no acute distress. He appears well nourished." },
{ "code": "skin", "name": "Skin", "durationMinutes": 1, "finding": "Skin is warm and dry without rash, jaundice, bruising, or visible pallor." },
{ "code": "breasts", "name": "Breasts", "durationMinutes": 1, "finding": "With the patient's consent and a chaperone present, examination shows no masses, tenderness, skin changes, or nipple discharge." },
{ "code": "lymph_nodes", "name": "Lymph Nodes", "durationMinutes": 1, "finding": "No cervical, supraclavicular, axillary, or inguinal lymphadenopathy is present." },
{ "code": "heent_neck", "name": "HEENT / Neck", "durationMinutes": 1, "finding": "Conjunctivae and oral mucosa are normal. Oropharynx is clear, neck is supple, and there is no thyromegaly or jugular venous distention." },
{ "code": "chest_lungs", "name": "Chest / Lungs", "durationMinutes": 1, "finding": "Breathing is unlabored. Lungs are clear to auscultation bilaterally without wheezes, crackles, or rhonchi." },
{ "code": "heart_cardiovascular", "name": "Heart / Cardiovascular", "durationMinutes": 1, "finding": "Heart has a regular rate and rhythm with normal S1 and S2 and no murmurs, rubs, or gallops. Peripheral pulses are symmetric." },
{ "code": "abdomen", "name": "Abdomen", "durationMinutes": 1, "finding": "The abdomen is soft and nondistended with mild epigastric tenderness. There is no guarding, rebound tenderness, palpable mass, or hepatosplenomegaly. Bowel sounds are normal." },
{ "code": "genitalia", "name": "Genitalia", "durationMinutes": 1, "finding": "With the patient's consent and a chaperone present, external genital examination is normal without lesions, masses, tenderness, or hernia." },
{ "code": "rectal", "name": "Rectal", "durationMinutes": 1, "finding": "With the patient's consent and a chaperone present, rectal tone is normal and no mass or tenderness is present. Brown stool without gross blood is noted." },
{ "code": "extremities_spine", "name": "Extremities / Spine", "durationMinutes": 1, "finding": "Extremities have full range of motion without edema, clubbing, cyanosis, or joint swelling. The spine is nontender." },
{ "code": "neuro_psych", "name": "Neuro / Psych", "durationMinutes": 1, "finding": "He is alert and fully oriented with normal speech, strength, sensation, coordination, gait, mood, and affect." }
],
"orderResponses": [],
"events": [],
"scoringCriteria": [
@@ -120,7 +133,14 @@
{ "id": "characterize_abdominal_pain", "title": "Characterize the abdominal discomfort", "actionType": "dialogue_choice", "targetCode": "abdominal_character", "points": 15, "rationale": "Location, quality, duration, severity, and radiation help characterize the source of pain." },
{ "id": "identify_relief", "title": "Identify relieving and aggravating factors", "actionType": "dialogue_choice", "targetCode": "relieving_factors", "points": 10, "rationale": "Temporary relief with food or antacids supports an acid-related pattern." },
{ "id": "screen_gi_bleeding", "title": "Screen for gastrointestinal bleeding", "actionType": "dialogue_choice", "targetCode": "associated_gi", "points": 15, "rationale": "Occasional black stool may represent melena and requires recognition." },
{ "id": "review_exposures", "title": "Review relevant exposures", "actionType": "dialogue_choice", "targetCode": "exposure_history", "points": 5, "rationale": "Recent illness, travel, and antibiotic exposure help refine the gastrointestinal differential." }
{ "id": "review_exposures", "title": "Review relevant exposures", "actionType": "dialogue_choice", "targetCode": "exposure_history", "points": 5, "rationale": "Recent illness, travel, and antibiotic exposure help refine the gastrointestinal differential." },
{ "id": "assess_appearance", "title": "Assess physical appearance", "actionType": "exam", "targetCode": "physical_appearance", "points": 5, "rationale": "General appearance helps assess acuity and physiologic compromise." },
{ "id": "examine_skin", "title": "Examine the skin", "actionType": "exam", "targetCode": "skin", "points": 5, "rationale": "Skin examination screens for pallor, jaundice, bruising, and other systemic clues." },
{ "id": "examine_lungs", "title": "Examine the chest and lungs", "actionType": "exam", "targetCode": "chest_lungs", "points": 5, "rationale": "A cardiopulmonary examination helps evaluate associated fatigue and lightheadedness." },
{ "id": "examine_heart", "title": "Examine the cardiovascular system", "actionType": "exam", "targetCode": "heart_cardiovascular", "points": 5, "rationale": "Cardiovascular examination helps assess presyncope and hemodynamic status." },
{ "id": "examine_abdomen", "title": "Examine the abdomen", "actionType": "exam", "targetCode": "abdomen", "points": 15, "rationale": "Focused abdominal examination identifies epigastric tenderness and screens for peritoneal signs or masses." },
{ "id": "perform_rectal_exam", "title": "Perform a rectal examination", "actionType": "exam", "targetCode": "rectal", "points": 10, "rationale": "Rectal examination can assess for current gross gastrointestinal bleeding when the history includes black stool." },
{ "id": "perform_neurologic_exam", "title": "Perform a neurologic examination", "actionType": "exam", "targetCode": "neuro_psych", "points": 5, "rationale": "A focused neurologic examination helps evaluate lightheadedness and exclude focal deficits." }
],
"references": [
{