Physical exam documentation: Difference between revisions

Revision as of 22:01, 1 July 2020

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+ , CRT <2s

Pelvic exam

Pelvic Exam (with Female Chaperone):

External: Normal

Vaginal: Normal

Bimanual: Negative

Authors:

@@ Line 3: / Line 3: @@
 ==Slit lamp exam==
-Slit Lamp with Floricine
+:Slit Lamp with Floricine
-Lids/lashes = nl
+:Lids/lashes = nl
-Conjunctiva = cl
+:Conjunctiva = cl
-Cornea = cl
+:Cornea = cl
-Anterior chamber = D/Q
+:Anterior chamber = D/Q
-Iris = R/R
+:Iris = R/R
-Lens = cl
+:Lens = cl
-No FB noted on extensive exam
+:No FB noted on extensive exam
 ==Knee==
@@ Line 23: / Line 23: @@
 ==Ortho lower extremity==
-bilateral lower extermities
+:bilateral lower extermities
-Sensory: SILT S/S/DP/SP/T
+:Sensory: SILT S/S/DP/SP/T
-FIRES TA, EHL, GS, FHL
+:FIRES TA, EHL, GS, FHL
-DP 2+ , CRT <2s
+:DP 2+ , CRT <2s
 ==Pelvic exam==
-Pelvic Exam (with Female Chaperone):
+:Pelvic Exam (with Female Chaperone):
-External: Normal
+:External: Normal
-Vaginal: Normal
+:Vaginal: Normal
-Bimanual: Negative
+:Bimanual: Negative
 [[Category:Documentation]]