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MT Training > Terminology > Physical Examination no bony or joint abnormalities No calf tenderness. No cellulitis. No cyanosis, clubbing or edema. No lymphedema. patella apprehension test peripheral circulation peripheral pulses are intact Phalen test pitting edema. pivot shift plantar flexion poststatic dyskinesia posterior drawer sign posterior sag sign radial pulse reflexes are 2+ or absent or trace. resting calcaneal stance reverse Lasegue test single leg stance snuffbox tenderness Speed test for biceps stump (in case of amputee patient) subtalar joint subungual hematoma talar tilt test Thompson test Tinel sign toes are downgoing too-many-toe sign (valgus deformity) two-beat clonus valgus/varus varicose veins. varus or valgus stress wide-based gait Yergason's test
NEUROLOGICAL: Alert, awake, and oriented x3. Alert, awake, and responsive. anosmia asterixis Babinski. Cerebellar function intact on finger-to-nose and rapid alternating movement Cranial nerves II through XII grossly intact. doll's eye reflex/sign Dysmetria extrapyramidal facial droop festinating gait finger-to-nose. flexors downgoing Follows simple commands. foot drop gait and station gaze / conjugate gaze / dysconjugate gaze gaze preference heel-to-shin. homonymous field defect horizontal nystagmus / vertical nystagmus / rotatory nystagmus hypacusis intention tremor Moro's sign or reflex motor impairment scale (MIS) motor power muscles of mastication No cranial nerve deficit. No focal deficits. No focal weakness. No headaches or seizures. No history of convulsion, seizures, TIA or CVA. noxious stimulation oculocephalic reflex oculocephalic maneuver pronator drift proprioception rapid alternating movements saccadic eye movements sensory exam - pinprick straight leg raising positive (negative) at 45 degrees suck and grasp tandem walk two-point proprioception vibratory sense intact Withdraws in response to tactile and painful stimuli.
GENITOURINARY/GENITALIA: balanitis chancre chordee cremasteric reflex circumcised phallus/penis condyloma epididymis epididymis and cords are normal genital warts glans is normal glans penis meatus is orthotopic, patent and clear no penile plaques or genital skin lesions orchiectomy perineum is normal Peyronie disease phallus prepuce priapism scrotal swelling scrotum Tanner Developmental Scale Tanner stage testes descended bilaterally testes have horizontal lie testicular tumor urethral groove webbed penis
PELVIC: adnexa negative for mass or tenderness adnexa nontender anterior lip of cervix bimanual exam bimanual rectovaginal exam BUS negative. BUS = (Bartholin's, urethral, Skene's) glands cervical motion tenderness cervix dilated to approximately 2 cm, vertex, -1 station (values given as eg - actual as dictated) cervix complete, 100% effaced, +2 station (values given as eg - actual as dictated) cervix 3 cm dilated, 50% effaced, -2 station (values given as eg - actual as dictated) cervix is long and closed cervix is posterior and clean cervix is smooth and normal in size cervix was high Chandelier sign EGBUS - external genitalia (EG), Bartholin, urethral and Skene (BUS) endometrial curetting fibroids GC and chlamydia culture hysterectomy, oophorectomy os is closed pelvic floor pelvic sidewalls are smooth specimens for KOH and wet prep supple pelvic floor TAHBSO uterine contour seems to be asymmetric uterus is anteverted, anteflexed, and regular in contour uterus is midposition uterus normal size uterus normal size, mobile, nontender uterus retroverted uterus was anteverted uterus was sounded at uterus, tubes, and ovaries vaginal apex is normal vagina and cervix without lesions or masses vagina is pink, moist and rugose vaginal vault
BREASTS: no adenopathy no dominant masses no gynecomastia (IN CASE OF MALE PHY EXAM) no nipple discharges or masses no skin or nipple retractions symmetrical
RECTAL: anal wall abscess ampulla black tarry stool bright red blood per rectum digital exam Exam deferred. fecal occult blood fissures fistula, condyloma heme-positive stools Hemoccult positive/negative hemorrhoid hemorrhoidal plexus hemorrhoids normal sphincter tone prostate prostate is smooth, nontender and without nodules or fluctuance rectal ampulla rectal vault size, shape, and mobility of prostate gland stool for guaiac
BACK/SPINE: kyphoscoliosis kyphosis lordosis No CVA tenderness. paravertebral scoliosis
SKIN: ABCD - asymmetry, border, color and diameter angel's kisses blanch branny desquamation bullae (bulla - singular) burrows caput medusae condyloma defurfuration dermatographism desquamation eczema. epidermal avulsion epidermolysis exophytic lesion flaking follicular, horny-spined areas folliculitis goatee of face honeycomb-crusted hyperkeratotic areas hyperpigmented plaques inoculation points icteric infiltrative lesion Janeway lesion keloid keratosis, actinic keratosis Klippel-Trenaunay-Weber syndrome lesions lichenification lymphangitic streaking lytic lesion maculopapular exanthem molluscum mottled, cyanotic Muehrcke lines / bands / sign neoplastic lesion Nikolsky sign no lesions, nodules or rashes no onychomycosis no streaking normal color, turgor, and temperature notable for tattoos Osler node papular, pustular rash petechiae pink and warm to touch pitted keratolysis pityriasis port-wine stains pruritic purpura purpuric lesions rosacea Rhus dermatitis ruddy complexion sandpapery rash satellite lesion scabies infestation scale-like rash scleredema seborrheic dermatitis skin cancer skin tag skin turgor sloughing spider angiomas. spider nevi stigmata of liver disease stork bites strawberry tongue tenting tyloma ulceration, induration unbroken and intact urticaria vascular streaking verruca vesicle vesicular lesions vesicular papules vesiculation warm and dry without rash warm, dry, and well perfused wart wheal wheal and flare reaction xerosis
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