Physical Exam Assistant

The Physical Exam Assistant allows you to generate a clean, organized, and clinically focused physical exam using just a short case summary. The output is focused and tailored to the clinical context — saving time while ensuring thoroughness.

✍️ How It Works

Intelligent Exam Generation

Provide a brief clinical summary:

Example Input:

78M, L sided weakness, R facial droop, slurred speech x 1 hour

Generated Physical Exam: The assistant creates a comprehensive, contextually appropriate examination including:

• General appearance - Overall clinical presentation and vital signs
• Focused system examination - Detailed neurologic exam for stroke symptoms
• Relevant screening - Cardiac, pulmonary, and other systems as indicated
• Structured assessments - NIHSS, GCS, or other validated scales when appropriate
• Pertinent findings - Documents relevant findings based on clinical context

Complaint-Specific Adaptation

The exam automatically focuses on the most relevant systems:

Chest Pain Input → Detailed cardiac + pulmonary exam
Abdominal Pain Input → Comprehensive GI + GU exam
Trauma Input → Systematic trauma survey + focused injury assessment
Headache Input → Detailed neurologic + HEENT exam
Dyspnea Input → Thorough cardiac + respiratory assessment

Smart Documentation Features

• Appropriate terminology - Uses correct medical language and exam techniques
• Logical organization - Follows standard head-to-toe or system-based approach
• Graduated detail - More detail for relevant systems, screening for others
• Normal variants - Includes appropriate "within normal limits" statements
• Clinical correlation - Exam findings that support or refute clinical suspicion

🖼️ Physical Exam Assistant Interface

The Physical Exam Assistant generates comprehensive, complaint-specific physical examinations from minimal input:

Key Features:

1. Input Area (top) - Enter brief case summary or chief complaint
2. Generate Function - Creates tailored physical exam documentation
3. Structured Output - Organized by body systems with relevant findings
4. Customization Options - Modify focus areas and level of detail

Dynamic Demonstration

See the Physical Exam Assistant in action:

This video shows how the assistant:

• Adapts to clinical context - Exam focus changes based on chief complaint
• Generates appropriate detail - Right level of documentation for the presentation
• Structures logically - Organized flow from general to specific findings

🔄 Flexible Follow-Up and Customization

Real-Time Modifications

Easily adjust the generated exam with natural language commands:

Expand specific systems:

• Expand the neurologic section with more detail
• Add a complete musculoskeletal exam
• Include a detailed psychiatric assessment

Modify clinical findings:

• Change NIHSS to 8
• Add bilateral lower extremity edema
• Note patient is intubated and sedated

Adjust documentation style:

• Format as bullet points
• Use more concise language
• Add more pertinent negatives

Template Integration

Customize to match your institution's preferred format:

Format using our physical exam template:
- Vital Signs:
- General Appearance:
- HEENT:
- Cardiovascular:
- Pulmonary:
- Abdomen:
- Neurologic:
- Skin:
- Extremities:

Progressive Documentation

Build the exam as you evaluate the patient:

1. Initial generation: Basic exam based on chief complaint
2. Add findings: Patient has 3/6 systolic murmur at LUSB
3. Include procedures: After intubation, bilateral breath sounds equal
4. Update status: Post-sedation, patient arousable to voice

✅ Key Benefits

⚡ Efficiency and Speed

• Instant generation - Complete exam documentation in seconds
• No template hunting - Automatically formats appropriate exam structure
• Quick modifications - Instantly updates as you add new findings

🎯 Clinical Accuracy

• Complaint-specific focus - Automatically emphasizes relevant body systems
• Appropriate detail level - Right amount of documentation for clinical context
• Professional terminology - Uses correct medical language and exam descriptions

📝 Documentation Quality

• Standardized format - Consistent structure
• Comprehensive coverage - Ensures no important systems are overlooked
• Billing support - Appropriate documentation for E/M level justification
• Medicolegal best practices - Thorough documentation for chart review

🚑 Emergency Medicine Optimized

• High-acuity adaptation - Appropriate for critically ill patients
• Trauma compatibility - Follows systematic trauma assessment principles
• Procedure integration - Documents exams around procedures and interventions
• Disposition support - Exam findings that support treatment decisions

💡 Advanced Features

Specialized Assessments

• Neurologic scales - Automatic NIHSS, GCS, cranial nerve testing
• Trauma surveys - Primary and secondary survey documentation
• Psychiatric exams - Mental status and behavioral assessments
• Pediatric adaptations - Age-appropriate examination techniques

🛠️ Pro Tips for Best Results

Input Optimization

• Include acuity level - stable vs critical changes exam focus
• Note procedures - intubated or sedated modifies neurologic exam
• Mention timing - on arrival vs after treatment provides context
• Add vital signs - Abnormal vitals guide examination emphasis

Common Use Cases

Stroke/Neurologic:

72F, acute onset left weakness, speech difficulty, NIHSS 12

Chest Pain:

58M, substernal chest pressure x 2 hours, diaphoretic, troponin elevated

Trauma:

23 y/o male, MVA, unrestrained driver, c/o chest and abdominal pain, stable vitals

Pediatric:

3yo, fever and irritability x 2 days, coughing, looks well, no vomiting

Clinical Applications

High-Volume Scenarios

• Fast track patients - Quick, focused exams for low-acuity complaints
• Busy shift documentation - Maintain quality when time is limited
• Multiple patient management - Consistent documentation across cases
• Sign-out preparation - Clear exam summaries for incoming providers

Quality Improvement

• Resident training - Demonstrates appropriate exam documentation
• Standardization - Reduces variation between providers
• Billing optimization - Ensures adequate documentation for coding
• Chart review preparation - Creates defensible examination records