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