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.

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+, CRT <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