Neuro Exam
CN2-12 intact b/l. EOMI. 5/5 strength in UE and LE. Intact sensation b/l. No dysmetria, no dysdokinesia. Neg protanator drift, neg romberg. Gait nl.
Hand Exam
CN2-12 intact b/l. EOMI. 5/5 strength in UE and LE. Intact sensation b/l. No dysmetria, no dysdokinesia. Neg protanator drift, neg romberg. Gait nl.
Hand Exam
Sensation: SILT in FDWS (radial), SF volar tip (ulnar), and IF (median)
Motor: + TU (radial), OK sign (median), X 2-3 (ulnar), F&E 1-5 against resistance, Wrist/finger extension off table (radial). Finger AB/AD-duction (ulnar), Thumb to pinky (median).
Vascular: CR<2s in all digits
Compartments Soft
Right hand:
FPL intact per routine. FDS and FDP grossly intact per routine. Extensor mechanisms grossly intact per routine. Able to oppose thumb to pinky. No overt evidence of malrotation. Median recurrent nerve intact to fine touch per routine.
Left hand:
FPL intact per routine. FDS and FDP grossly intact per routine. Extensor mechanisms grossly intact per routine. Able to oppose thumb to pinky. No overt evidence of malrotation. Median recurrent nerve intact to fine touch per routine.
Isolation of each digit
IF: FDS, FDP, extenstion intact with PROM and against resistance. No pain on movement. RDN/UDN intact. 2 pt discrimination intact. CR < 2s. Soft compartment. No gross deformity.
MF: FDS, FDP, extenstion intact with PROM and against resistance. No pain on movement. RDN/UDN intact. 2 pt discrimination intact. CR < 2s. Soft compartment. No gross deformity
RF: FDS, FDP, extenstion intact with PROM and against resistance. No pain on movement. RDN/UDN intact. 2 pt discrimination intact. CR < 2s. Soft compartment. No gross deformity
SF: FDS, FDP, extenstion intact with PROM and against resistance. No pain on movement. RDN/UDN intact. 2 pt discrimination intact. CR < 2s. Soft compartment. No gross deformity
Thumb: FPL, EPL, EPB, APL intact per routine. RDN/UDN intact per routine. CR < 2s. No gross deformity. Compartments soft.
Patient can stand on tiptoes, dorsiflex bilaterally, rise bigtes b/l, and can can squat
Straight leg test ***
Compartment Syndrome
Compartments soft , no pain in compartments on passive stretch, no pallor, warm, + distal pulses, + active movement in ***
ABD RLQ Pain
Soft, NTND, no rigidity, no rebound, no guarding, Neg. Obturator's Sign, Neg. Psoas Sign.
ABD RUQ Pain
Soft, NTND, no rigidity, no rebound, no guarding. Neg Murphy's Sign.
Eye Exam
VF (Visual Fields): Intact by 4
VA (Visual Acuity): 20/20 w/ PH
EOM (extraocular muscles): Intact w/o diplopia
IOP: 20
SLE
EXT (external structures): normal
LLL (lids lashes and lacrimation): No lesions
CS (conjunctiva and sclera): White And Quiet
K (cornea): No Fluorescein Uptake
AC (anterior chamber): Deep and Quiet
I (iris): Round and Reactive
L (lens): Clear
V (vitreous)
DFE (Fundoscopic)
R (Retina): Sharp Disc Margins
M (macula)
V (vessels)
P (periphery)
D (disk)
GU Male
Testicular exam with normal lie and CMR bilaterally, no significant erythema, tenderness or swelling appreciated. No appreciable inguinal hernia bilaterally. No rashes or lesions. No penile discharge. No blood at meatus.
Pelvic Exam Female
Pelvic Exam: Closed Os, *purulent mucopurulent cervical exudate. *cervix Frability, *cervical erythema, edema. *Adnexal Tenderness, *CMT. *Vaginal Vault Discharge
Head Trauma
No septal hematoma, TM x2 clear w/o e/o hemotypanum or CSF rhinorrhea, no battle sign, raccoon eyes or csf rhinorrhea, no e/o entrapment, no diplopia on EOM, PERRL, EOMI. No facial tenderness over zygoma, mandible or maxilla. TMJ intact. Midface stable. Nose midline without significant deviation. No ML C-spine TTP.
Rectal Exam
RECTAL EXAM: no fissures, no hemorrhoids, +brown stool, no melena, no bright red blood.
Shoulder Exam
No tenderness to shoulder, no limited flexion and abduction of shoulder secondary to pain, rotator cuff tests are negative. Able to touch opposite shoulder with hand. No deformities. Radian, medial, and ulnar nerves intact to motor and sensation. Good distal pulses and good cap refill
Knee Exam
Full range of motion of right ankle, right knee without pain, (-) right patellar tenderness. Negative mcburney's, negative Lachman's, posterior drawer test. 5/5 strength of ankle, knee and hip with stable gait. No effusion appreciated.
