Physical exam documentation: Difference between revisions
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GENERAL APPEARANCE | GENERAL APPEARANCE | ||
NAD, activity normal for age, well developed/ well nourished, no cyanosis, | NAD, activity normal for age, well developed/ well nourished, no cyanosis, | ||
pallor, or diaphoresis | pallor, or diaphoresis. | ||
EYES | EYES | ||
lids/conjunctiva normal | lids/conjunctiva normal. | ||
EARS/NOSE/THROAT | EARS/NOSE/THROAT | ||
Mucous membranes moist, nares normal, lips/teeth normal uvula midline without | Mucous membranes moist, nares normal, lips/teeth normal uvula midline without | ||
oral pharyngeal erythema, exudate or swelling | oral pharyngeal erythema, exudate or swelling | ||
TMs normal bilaterally | TMs normal bilaterally. | ||
No lymphangitis/lymphedema. | No lymphangitis/lymphedema. | ||
HEAD/NECK | HEAD/NECK | ||
normocephalic atraumatic, no facial trauma, neck is supple | normocephalic atraumatic, no facial trauma, neck is supple. | ||
RESPIRATORY | RESPIRATORY | ||
respiratory effort normal, speaks in full sentences, no tripod position, no | respiratory effort normal, speaks in full sentences, no tripod position, no | ||
accessory muscle use | accessory muscle use. | ||
Lungs clear to auscultation without rhonchi, wheezes, rales | Lungs clear to auscultation without rhonchi, wheezes, rales | ||
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SKIN | SKIN | ||
Warm, pink and dry. No rashes, dermatoses, petechiae or lesions | Warm, pink and dry. No rashes, dermatoses, petechiae or lesions. | ||
NEUROLOGICAL | NEUROLOGICAL | ||
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PSYCH | PSYCH | ||
Normal mood and affect | Normal mood and affect. | ||
[This template meets CMS level 5 standards] | [This template meets CMS level 5 standards] | ||
Revision as of 01:38, 19 November 2021
Physical exam
GENERAL APPEARANCE NAD, activity normal for age, well developed/ well nourished, no cyanosis, pallor, or diaphoresis.
EYES lids/conjunctiva normal.
EARS/NOSE/THROAT Mucous membranes moist, nares normal, lips/teeth normal uvula midline without oral pharyngeal erythema, exudate or swelling TMs normal bilaterally. No lymphangitis/lymphedema.
HEAD/NECK normocephalic atraumatic, no facial trauma, neck is supple.
RESPIRATORY respiratory effort normal, speaks in full sentences, no tripod position, no accessory muscle use. Lungs clear to auscultation without rhonchi, wheezes, rales
CARDIAC Regular rate and rhythm, no edema.
MUSCLES/EXTREMITIES No abnormal range of motion, no swelling.
SKIN Warm, pink and dry. No rashes, dermatoses, petechiae or lesions.
NEUROLOGICAL speech clear appropriate, level of consciousness normal, judgement/competence normal. Gait normal. Alert and oriented to person, place situation and time.
PSYCH Normal mood and affect.
[This template meets CMS level 5 standards]
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