Physical exam documentation: Difference between revisions
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==Ortho normal== | ==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. | 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+, CR <2s | |||
==Ortho lower extremity== | |||
bilateral lower extermities | |||
Sensory: SILT S/S/DP/SP/T | |||
FIRES TA, EHL, GS, FHL | |||
DP 2+ , CR<2s | |||
==Pelvic exam== | ==Pelvic exam== | ||
Revision as of 09:38, 14 March 2018
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.
Slit lamp exam
Slit Lamp with Floricine 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 blot 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+, CR <2s
Ortho lower extremity
bilateral lower extermities Sensory: SILT S/S/DP/SP/T FIRES TA, EHL, GS, FHL DP 2+ , CR<2s
Pelvic exam
Pelvic Exam (with Female Chaperone): External: Normal Vaginal: Normal Bimanual: Negative