Physical exam documentation

Cellulitis

Compartments soft. <2sec CRT. +2 pulse. Normal sensation. Nerves and tendons intact. No tenderness to palpation proximal or distal. No skip lesions. No fluctuance or signs of drainable abscess. No palpable crepitus.

Slit lamp exam

Slit Lamp with fluorescein

Lids/lashes = nl

Conjunctiva = cl

Cornea = cl

Anterior chamber = D/Q

Iris = R/R

Lens = cl

No FB noted on extensive exam

Knee

Anterior/posterior/varus/valgus/McMurry's tests negative. Patella in place. No instability of knee. Negative Ballottement test. Neg axial load.

Ortho normal

No open fracture. Compartments soft. <2sec CRT. +2 pulse. Normal sensation. Nerves and tendons intact. No tenderness to palpation proximal or distal. No retained foreign body or signs of infection.

Ortho upper extremity

bilateral upper extremities fires ain/pin/u slit fwds/sf/if, radial 2+, CRT <2s

Ortho lower extremity

bilateral lower extermities

Sensory: SILT S/S/DP/SP/T

FIRES TA, EHL, GS, FHL

DP 2+ , CRT <2s

Rectal Exam

The RN was in plain view of my exam for the duration; normal external anus and normal tone. No palpable masses, normal mucosa, brown stool.

Pelvic exam

Pelvic Exam (with Female Chaperone):

External: Normal

Vaginal: Normal

Bimanual: Negative