PROCEDURE DATE  ....   ....
LAST NAME FIRST NAME       . ADMIT   MD
MR# S.S#              Present Time
CONSULTING MD INSURANCE            ADMIT TIME
REF.MD DOB  

 

INDICATION

CRS (average risk)  occult + stools occult + stools and anemia iron def. anemia hematochezia
CRS (high risk)  change bowel habits (C) change bowel habits (D) bloody stools surveillance IBD
  surveillance polyps   constipation diarrhea s/p "diverticulitis"  
RLQ pain   LLQ pain RUQ pain diffuse abdominal cramps  

 

 AGE Male Female  ASA:

 advanced to :   cecum     terminal ileum                            sigmoid colon   hepatic flexure   surgical anastomosis

Procedure:

 

Preparation:        

Good

Excellent

 Fair poor (completed exam) poor (not completed exam)
Good right poor left good left but poor right

but poor cecum

    
         
         

 

        
Conscious sedation        
  Demerol : mg Oxygen (given) :          phenergan mg  
  Versed  : mg      
         

 

 
     
 
    
rectum:  Normal mucosa ,no polyps , masses, colitis
   sigmoid colon normal mucosa, no masses, polyps or colitis
     
digital exam (no masses noted)          skin tags (present)
   tourtuosity with narrowing and fixation of the sigmoid loops
    no tourtuosity or narrowing
normal sphincter tone     lax sphincter tone   redundant loops with no fixation
   
no masses , fistula , fissures , with normal prostate    
     
Prostate    
not enlarged   prominent lobes   nodular    hard    
      
hemorrhoids    Diverticula
Grade I     grade II      grade III     grade IV
    few    multiple   marked    none
     
 
    
mucosa
  mucosa appeared erythematous, edematous,friable and ulcerated
normal     friable     erythematous     markings (loss)    
    erythema , luminal narrowing, and edema present
     
mass with irregular friable borders   mass with irregular friable borders
     
     
     
     
     
rectal polyps     sigmoid colon  polyps  
     
Polyp (Single)             Polyps (multiple)          Polyp (Single)              Polyps (multiple)       
Micropolyp     small      Medium       Large   Micropolyp     small      Medium       Large
     
rectal polyp removed with: (Singular)   sigmoid polyp removed with: (Singular)
snare cautery (hot)                      good hemostasis   snare cautery (hot)                      good hemostasis was achieved
fulguration   fulguration
cold snare   cold snare
hot biopsy cold biopsy   hot biopsy cold biopsy
cold biopsy   cold biopsy
     
rectal polyps removed with: (plural)   sigmoid polyps removed with: (plural)
     
snare cautery (hot)                      good hemostasis    snare cautery (hot)                      good hemostasis was achieved
fulguration   fulguration
cold snare   cold snare
hot biopsy cold biopsy   hot biopsy cold biopsy
cold biopsy   cold biopsy
     
A total of polyps were removed from rectum.   A total of polyps were removed from sigmoid colon.
     
 
     
descending colon Normal mucosa , no masses polyps or colitis
  transverse colon  Normal mucosa , no masses polyps or colitis noted
     
diverticulosis
  diverticulosis
Polyp (singular)
  polyp (single)
     
Polyp (multiple)   Polyp (multiple)
friable mucosa with loss of vascular markings   friable mucosa with loss of vascular markings
mass with irregular friable borders   mass with irregular friable borders
     
     
     
     
     
     
     
descending colon polyps      transverse colon polyps  
     
Polyp (Single)             Polyps (multiple)          Polyp (Single)             Polyps (multiple)       
Micropolyp     small      Medium       Large   Micropolyp     small      Medium       Large
     
descending colon  polyp removed with: (Singular)    transvere colon  polyp removed with: (Singular)
snare cautery (hot)                      good hemostasis was achieved   snare cautery (hot)                      good hemostasis was achieved
fulguration   fulguration
cold snare   cold snare
hot biopsy cold biopsy   hot biopsy cold biopsy
cold biopsy   cold biopsy
     
descending colon  polyps removed with: (plural)    transverse colon  polyps removed with: (plural)
     
snare cautery (hot)                      good hemostasis was achieved   snare cautery (hot)                      good hemostasis was achieved
fulguration   fulguration
cold snare   cold snare
hot biopsy cold biopsy   hot biopsy cold biopsy
cold biopsy   cold biopsy
     
A total of polyps were removed from descending colon   A total of polyps were removed from transverse colon.
     
 
     
ascending colon normal normal mucosa   cecum   normal mucosa
     
diverticula noted   A single polyp was found and removed as detailed below:
Polyp (singular)   Multiple AVMs
     
Polyp (multiple)   Single AVM
friable mucosa with loss of vascular markings   multiple aphthous ulcerations
     
mass with irregular friable borders   mass with irregular friable borders
     
     
     
     
     
     
    subotimal prep in the cecum -irrigated to visualize the mucosa
     
ascending colon polyps     cecum  
     
Polyp (Single)             Polyps (multiple)          Polyp (Single)             Polyps (multiple)       
Micropolyp     small      Medium       Large   Micropolyp     small      Medium       Large
     
ascending colon  polyp removed with: (Singular)   cecal  polyp removed with: (Singular)
snare cautery (hot)                      good hemostasis was achieved   snare cautery (hot)                      good hemostasis was achieved
fulguration   fulguration
cold snare   cold snare
hot biopsy cold biopsy   hot biopsy cold biopsy
cold biopsy   cold biopsy
     
ascending colon polyps removed with: (plural)    cecal  polyps removed with: (plural)
     
snare cautery (hot)                      good hemostasis was achieved   snare cautery (hot)                      good hemostasis was achieved
fulguration   fulguration
cold snare   cold snare
hot biopsy cold biopsy   hot biopsy cold biopsy
cold biopsy   cold biopsy
     
A total of polyps were removed from ascending  colon.   A total of polyps were removed from cecum.
     
     
 
     
terminal ileum normal   Therapeutic and Special techniques used
     
     
Unable to intubate the terminal ileum after multiple attempts   Snare cautery polypectomy
     
not intubated    
swelling noted in the terminal ileum  
    Polyp fulguration
a single aphthous ulceration   Saline assisted polyp removal
multiple aphthous ulcerations   Mucosal tattooing
     
mass with irregular friable borders   NO SPECIAL PROCEDURES WERE USED:
     
     
     
     
     
     
    ARGON PLASMA COAGULATOR
terminal ileum polyp             20 Watts       40 Watts    60 Watts
    5 sec        10 sec       15 sec         20 sec
Polyp (Single)             Polyps (multiple)           
Micropolyp     small      Medium       Large    
     
 Polyps removed with:    
snare cautery    
fulguration    
     
     
     
     
     
     
 
 
     
     
     
     

Impression

 
Normal Study Internal hemorrhoids diverticulosis   Micropolyps removed  radiation proctitis
Colon polyp (one) Multiple colon polyps ulcerative colitis Ischemic colitis  nonspecific colitis 
         
         

Recommendations

 
F/U Dr. Monte F/U Dr. Gaziano F/U Concha   F/U Dr. Powers F/U Dr. Strom
F/U Referring attending F/U MCGlone F/U Dr. Schmelzel  F/w MD  F/U Urology

 

 F/U  Appointment in :

 days   Weeks   months
    years prn  get lost

 
 F/U Colonoscopy  in 10 years  5 years   3-5 years   3 years
  1 year  6months  3 months   REPEAT

 

Educational material provided at discharge

   no complications with procedure Electronic Signature provided
multiple images were taken    

Pathology Specimens

 

No path specimens were taken

 tissue was retrieved tissue taken but  not retrieved    
       
       
  specimens in jar A specimens in jar B  

 

Therapeutic Recommendation :

 
PPI therapy (start) Stop all NSAIDS  check coulter q 24 hrs   Continue to hydrate CWPM
PPI high dose Hold ASA coulters q 12 hours Maintain Hb of 10 mg /dl
         
PPI one dose per day

(continue)

 hold ASA , Plavix coulters q8 hours Reduce IV fluid rate
         
PPI therapy IV hold ASA, Plavix and warfarin coulters q6 hours Control heaving
         
Mesalamine Colazal (balsalazide disodium) Dipentum (olsalazine) Azulfidine (sulfasalazine) Zegrid
Asacol (mesalamine) mesalamine (Pentasa) Rowasa  
         
         
         
         
         
         

 

 

 

 

 

 

 

 

VITALS

BP.sys P R TEMP ....BMI:
BPdias     WT: ...  HT:....feet....inches......................

Physcal Exam

PHYSICAL EXAMINATION

Red_SwirlF000.gif (187 bytes)

         
HYDRATION Good    adequate Dry
GENERAL Focused Expanded Detailed
EYE Focused Expanded Detailed
EAR NOSE  & THROAT Focused Expanded Detailed
NECK Focused Expanded Detailed
         
CARDIAC Focused Expanded Detailed
LUNG Focused Expanded Detailed
ABDOMINAL EXAM Focused Expanded Detailed
         
PERIPHERAL PULSES Focused Expanded Detailed
NEUROLOGICAL EXAM Focused Expanded Detailed
PSYCHIATRIC Focused Expanded Detailed
         
FEMALE EXAM Focused Expanded Detailed
    FEMALE EXAM Focused Expanded Detailed
    RECTAL EXAM heme negative heme positive deferred
         
MUSCULOSKELETAL Focused. Expanded Detailed
LYMPHATICS Focused Expanded Detailed.
SKIN Focused Expanded Detailed.

 

 

 

 

 

General

Red_SwirlF000.gif (187 bytes)

Demeanor
hostile     argumentative       anxious      hyper agitated
tearful       wincing      chronically ill appearing     very pleasant
 
Grooming and Personal hygiene
normal     poor       very poor        unkempt
 
Body Habitus
morbid obesity      obese      cachectic      frail       thin      average built
 
Gait and posture
normal gait    staggering gait      stooped      old age     broad based
 
Involuntary Movements
intention tremor     dystonia     athetosis      oral dyskinesis
 
.... Other findings
Parkinsonian facies     Graves disease      Cushing's Moon face
 
ADDITIONAL STATEMENTS ?

Eyes

Red_SwirlF000.gif (187 bytes)

   
  Bilateral iridectomies : unable to visualize the fundus
  Bilateral cataracts : unable to visualize the fundus
  Not cooperating with eye exam : unable to visualize the fundus
   
  Funduscopic Examination
Right papilledema   hypertensive retinopathy   normal fundus
Left papilledema   hypertensive retinopathy   normal fundus
   
   
  Ocular Discharge
Right watery   mucoid  purulent   no discharge
Left watery   mucoid  purulent   no discharge
   
  Lumps and Swelling
Right Sty   Chalazion  Dacryocystitis   Episcleritis   Xanthelasma
Left Sty   Chalazion   Dacryocystitis   Episcleritis   Xanthelasma
   
  Conjunctival inflammation
Right conjunctivitis   iritis   glaucoma   subconjunctival hemorrhage
   
Left conjunctivitis   iritis    glaucoma   subconjunctival hemorrhage
   
  Other findings...
Right hyphema    ptosis      exophthalmos

periorbital edema    Horner's    Adie's pupil

corneal abrasion   Argyll Robertson pupils
   
Left Other findings...

hyphema    ptosis    exophthalmos

periorbital edema    Horner's    Adie's pupil

corneal abrasion    Argyll Robertson pupils
  ADDITIONAL STATEMENTS ?

Ear

Red_SwirlF000.gif (187 bytes)

 
 
Right Eardrum
normal     perforation    bullous myringitis

otitis media     tympanosclerosis     unable to visualize
 
Left Eardrum
normal     perforation      bullous myringitis

otitis media      tympanosclerosis       unable to visualize
 
Right Pinna
normal     laceration     erythematous      hematoma

tophi      leprosy      carcinoma      rheumatoid nodule
 
Left Pinna
normal lacerationminiaturespacer.gif (889 bytes)  erythematousminiaturespacer.gif (889 bytes)hematoma

tophi miniaturespacer.gif (889 bytes)leprosy miniaturespacer.gif (889 bytes)carcinoma miniaturespacer.gif (889 bytes) rheumatoid nodule
 
Right external canal
normal miniaturespacer.gif (889 bytes)friable miniaturespacer.gif (889 bytes) swollen miniaturespacer.gif (889 bytes)pus is present

foreign bodyminiaturespacer.gif (889 bytes) wax miniaturespacer.gif (889 bytes) impacted miniaturespacer.gif (889 bytes) vesicles

 
Left external canal
normal miniaturespacer.gif (889 bytes)friableminiaturespacer.gif (889 bytes)  swollen miniaturespacer.gif (889 bytes)pus is present

foreign body miniaturespacer.gif (889 bytes)waxminiaturespacer.gif (889 bytes) impacted  miniaturespacer.gif (889 bytes)vesicles
 
ADDITIONAL STATEMENTS ?

Nose

Red_SwirlF000.gif (187 bytes)

 
Right nostril
No nasal septum hematomaminiaturespacer.gif (889 bytes)no crusted bloodminiaturespacer.gif (889 bytes) crusted blood present
no evidence of active bleeding miniaturespacer.gif (889 bytes) no polyps detected
 
active bleeding miniaturespacer.gif (889 bytes)nasal mucosa appears swollen
polyps detected
 
Left nostril
No nasal septum hematomaminiaturespacer.gif (889 bytes)no crusted bloodminiaturespacer.gif (889 bytes) crusted blood
no evidence of active bleedingminiaturespacer.gif (889 bytes) no polyps detected
 
active bleedingminiaturespacer.gif (889 bytes) nasal mucosa appears swollen
polyps detected
 
Septum
Deviated miniaturespacer.gif (889 bytes)perforated miniaturespacer.gif (889 bytes)No nasal septum hematoma
 
Nasal Pyramid
normal          depressed fracture          laceration
ADDITIONAL STATEMENTS ?

 

Throat

Red_SwirlF000.gif (187 bytes)

 
TONSILS no exudates    bilateral exudates      diffuse mild erythema

redness and vascularity of the pillars and uvula is mild with no exudates

redness is diffuse and intense with no exudates

oral pharynx is erythematous with exudates on the tonsils with anterior cervical node enlargement

oral pharynx is erythematous with exudates on the tonsils with posterior cervical node enlargements

the throat is erythematous dull red with gray exudates over the uvula, pharynx and tongue

AIRWAY PATENCY no obstruction (wide open)                        appears restricted

Neck

Red_SwirlF000.gif (187 bytes)

 
 
+ Kernig and Brudzinski's sign
 
General
Trapezius muscle tenderness miniaturespacer.gif (889 bytes)(+) More than 20 point tender spots over trapezius miniaturespacer.gif (889 bytes)no trapezius muscle tenderness
 
Carotids
(+) right carotid bruitminiaturespacer.gif (889 bytes)(+) left carotid bruitminiaturespacer.gif (889 bytes)(+) bilateral carotid bruits
 
Thyroid Gland
diffusely enlarged miniaturespacer.gif (889 bytes)multinodular goiterminiaturespacer.gif (889 bytes)miniaturespacer.gif (889 bytes)(RT) single nodularminiaturespacer.gif (889 bytes) (LT) single nodular miniaturespacer.gif (889 bytes)normal thyroid
Lymph nodes

(+) small mobile non-tender nodes small mobile non-tender nodes

     
  RIGHT LEFT
     
Supraclavicular nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged non-tender enlarged tender miniaturespacer.gif (889 bytes)enlarged non-tender
Tonsillar nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Submandibular nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Posterior auricular enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Pre auricular enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
     
ADDITIONAL STATEMENTS ?

Lungs

Red_SwirlF000.gif (187 bytes)

 
Retractions: absent              subcostal                intra-costal
Adventitious sounds

bilateral expiratory wheezingminiaturespacer.gif (889 bytes) localized wheezing Rt lungminiaturespacer.gif (889 bytes)localized wheezing Lt lung

bilateral basilar ralesminiaturespacer.gif (889 bytes) localized basilar rales Rt lungminiaturespacer.gif (889 bytes) localized basilar rales Lt lung

bilateral rhonchi miniaturespacer.gif (889 bytes) localized rhonchi Rt lungminiaturespacer.gif (889 bytes) localized rhonchi Lt lung

clear lungs with no adventitious sounds

Air exchange :

moving air well miniaturespacer.gif (889 bytes) limited air exchange

Percussion Note

Resonant over both lung fields

dullness over the right lung base

dullness over the left lung base

hyperresonant over both lung fields              miniaturespacer.gif (889 bytes) CHEST WALL : With Increased AP Diameter

Tactile Fremitus And Transmitted Voice Sounds

normal bronchophony, egophony, and whispered pectoriloquy

decreased bronchophony, egophony, and whispered pectoriloquy Rt lung miniaturespacer.gif (889 bytes) LFT lung

Increased bronchophony, egophony, and whispered pectoriloquy Rt lung miniaturespacer.gif (889 bytes) LFT lung

obscured by wheezes (bronchophony, egophony, and whispered pectoriloquy)

Breath Sounds

normal breath sounds over all lung fields

decreased miniaturespacer.gif (889 bytes) Rt lungminiaturespacer.gif (889 bytes) LFT lung

Increasedminiaturespacer.gif (889 bytes) Rt lungminiaturespacer.gif (889 bytes) LFT lung

absent miniaturespacer.gif (889 bytes) Rt lungminiaturespacer.gif (889 bytes) LFT lung

Trachea

Midline

deviated to the right

deviated to the left

unable to determine if deviated

 

Cardiac

Red_SwirlF000.gif (187 bytes)

 

(NO) Jugular venous distention      (YES ) for jugular venous distention

PMI : normal     displaced      non-detected
AUSCULTATION :  distant heart sounds    rate and rhythm are normal    irregular rhythm   occasional ectopy
PALPATION : (+) parasternal lift    (-) parasternal lift    (+) biventricular rock   (-) biventricular rock
 
MURMURS : No murmurs

Aortic stenosis murmur

Aortic insufficiency

Mitral regurgitation

Mitral stenosis

Grade II/VI murmur Grade III/VI murmur Grade IV/VI murmurGrade V/VI murmur Grade VI/VI murmur
S1 :normal         increased sound           decreased sound          split
S2 :normal         increased sound           decreased sound          split
S3 :no S3 present           an S3 is present
S4 :no S4 present           an S4 is present
Peripheral edema : no edema     +1 edema     +2 edema    +3 edema   +4 edema

 

Peripheral Vascular

Red_SwirlF000.gif (187 bytes)

     
  RIGHT LEFT
     
Radial pulse strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent
Ulnar pulse strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent
Femoral pulse strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent
Dorsalis pedis pulse strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent
Posterior tibial strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent strongminiaturespacer.gif (889 bytes)weakminiaturespacer.gif (889 bytes)absent
     

 

 

miniaturespacer.gif (889 bytes)All pulses are equal bilateral and symmetrical
miniaturespacer.gif (889 bytes)Unequal peripheral pulses
miniaturespacer.gif (889 bytes)vascular ulcers present in the lower extremities
miniaturespacer.gif (889 bytes)Pulsatile abdominal mass is present.
ADDITIONAL STATEMENTS ?

 

Abdominal Exam

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BOWEL SOUNDS:normal  absent sounds  decreased bowel sounds  high pitched bowel sounds
TENDERNESS :no abdominal tenderness  epigastric tenderness  RUQ tenderness

diffuse abdominal tenderness  RLQ tenderness LUQ tenderness  LLQ tenderness

SIGNS :(+) Murphy's sign (+) McBurney's (+) Rovsing's (+) Psoas (+)Rt CVA(+) LT CVA

no CVA tenderness (+)succussion splash (-)succussion splash Turner's Sign  Cullen's
LIVER /SPLEEN:no hepatosplenomegaly       enlarged nontender liver      enlarged and tender liver      enlarged and nodular
splenomegaly
GUARDING :      there is no abdominal guarding        there is diffuse abdominal guarding       there is voluntary abdominal guarding
REBOUND TENDERNESS : there is no rebound      there is diffuse rebound       point rebound over right lower quadrant
RECTUM :heme negative        heme positive         refuses rectal           deferred rectal

 rectal mass       rectal tenderness
ICTERIC: YES           NO
STIGMATA OF CHRONIC LIVER DISEASE

Palmar erythema

Dupuytren's contractures

Gynecomastia

Spider angiomata

Ascites

 NO

 YESNO

 YESNO

 YESNO

 YESNO

 YESNO

  
Other abdominal findings : (+) abdominal distention (-) abdominal distention
 

 

Genital (female)

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GYNE EXAM   deferred                 refuses pelvic exam

EXTERNAL GENITALIA

normal external genitalia       normal external genitalia with no evidence of swelling of labia's

abnormality noted ..

INTROITUS normal with no excoriations or erythema     erythematous with excoriations
VAGINAL VAULT no vaginal discharge      Cheesy,lumpy vaginal discharge         small amount of blood with no evidence of active bleeding
CERVICAL MOTION TENDERNESS

No CMT       (positive ) cervical motion tenderness

ADNEXA      mild bilateral adnexal tenderness        moderate to severe bilateral adnexal tenderness

no bilateral adnexal tenderness

RT ADNEXA : normal with no tenderness         RT with mild tenderness      RT with mass and tenderness

RT marked tenderness
LT ADNEXA : normal with no tenderness      LT with mild tenderness      LT with mass and tenderness

LT marked tenderness
UTERUS: normal       normal size but tender      enlarged with irregular contour
ESTIMATED UTERINE SIZE: 8 wks       12wks      16 wks     18 wks     24wks      greater than 30 wks
UTERINE POSITION      ANTE-FLEXED      ANTE-VERTED        MIDPLANE       RETRO-VERTED

RETRO-FLEXED

 

Genital (male)

Red_SwirlF000.gif (187 bytes)

MALE GENITAL EXAMdeferred
EXTERNAL GENITALIA

normal external genitalia

abnormality noted ..

oval dark red, painless erosion with indurated base

a cluster of small vesicles, followed by a shallow, painful , non-indurated ulcers on red bases

excrescences which are moist

indurated nodules which are not tender

phimosis is present

paraphimosis is present

penile discharge present

balanitis
SCROTUM normal         Scrotal edema

RT testicle is high riding     LT testicle is high riding          RT testicle is tender        LT testicle is tender

TESTIS        no masses         RT testicle is absent          LT testicle is absent

 RT testicle with nodule         LT testicle with nodule
EPIDIDYMIS

 nontender        RT epididymis is tender         LT epididymis is tender

HERNIA no hernias          RT inguinal hernia       LT inguinal hernia         RT incarcerated hernia       LT incarcerated hernia
FEMORAL AREA: no adenopathy          RT adenopathy          LT adenopathy
PROSTATE EXAM: not enlarged        2x enlargement      enlarged and tender

RT  lobe nodule          Lt  lobe nodule        very hard and enlarged

 

Musculoskeletal

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ANKLE

Sprains: Rt        Lt

GRADE 1      GRADE 2     GRADE 3

KNEE :

Rt       Lt

MCL sprain     LCL sprain       ACL damage         PCL damage      Medial Meniscus damage        Lateral Meniscus damage       effusion

HIP FX:

Rt      Lt

Surgical neck    Intertrochanteric      Subtrochanteric
Wrist :

Rt      Lt

(+) tenderness in the anatomical snuff box   diffuse tenderness         deQuervain's Tenosynovitis

carpal tunnel         Colle's fracture deformity       growth plate injury
Hand :
     
  RIGHT LEFT
  Digit # Digit #
Subungual hematoma 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
Laceration 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
Burn 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
Crush injury 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
Cellulitis 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
Paronychia 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
Tenosynovitis 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5 1miniaturespacer.gif (889 bytes)2miniaturespacer.gif (889 bytes)3miniaturespacer.gif (889 bytes)4miniaturespacer.gif (889 bytes)5
     
Elbow :

Rt    Lt

Nurse Maids elbow      sprain      ecchymosis            olecranon bursitis
 
Forearm :

Rt    Lt

distal fore-arm swelling        Laceration      burn partial thickness      open fracture       diffuse non specific soft tissue swelling
Shoulder :

Rt         Lt

anterior dislocation         humeral head fracture         subacromial bursitis        bicipital tendinitis
Clavicle :

Rt        Lt

AC Separation Grade1or 2           AC Separation Grade 3             clavicle mid fx

C-SPINE :

diffuse tenderness over the trapezius muscle

point tenderness over the c-spine
 
ADDITIONAL STATEMENTS ?

 

Neurological

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Alert but very confused
Restless, confused , agitated
Lethargic, distant , sleepy
ADDITIONAL STATEMENTS ?

Neurological 

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MENTAL STATUS : Alert, keenly responsive

Eyes are open , awake but not verbal

not alert, but easy to arouse by minor stimulation to obey, answer or respond

no alert, requires repeated stimulation to attend, or is obtunded

responds only with reflex motor or autonomic effect or totally unresponsive , flaccid, areflexic.
LEVEL OF CONSCIOUSNESS QUESTIONS (must answer the month and age)

answers questions correctly     answers (1 of 2 ) question correctly

answers neither question correctly

LEVEL OF CONSCIOUSNESS COMMANDS (able to open eyes on command and grip and release

performs both tasks correctly     performs one task correctly

performs neither task correctly
BEST GAZE

Unable to determine gaze abnormalities

normal

partial gaze palsy

has a gaze paresis

VISUAL FIELDS

no visual fields loss     complete hemianopia

bilateral hemianopia    unable to determine
LANGUAGE: no aphasia      mild to moderate aphasia      severe aphasia      mute global aphasia
DYSARTHRIA: no dysarthria     mild to moderate dysarthria    severe dysarthria

intubated or other physical barrier (unable to evaluate)
CRANIAL NERVES 2-12 were intact     7 th central nerve palsy      7th peripheral nerve palsy

3,4, 6 nerve intact    Rt Horner's     Lt Horner's     Unable to determine
LT-MOTOR

UPPER :

complete paralysis   minimal effort against gravity      some effort against gravity (+)drift

no drift (good motor function)     unable to determine

LOWER :

complete paralysis    minimal effort against gravity      some effort against gravity (+)drift

(+) no drift (good motor function)     unable to determine
RT-MOTOR

UPPER:

complete paralysis    minimal effort against gravity      some effort against gravity (+)drift

no drift (good motor function)     unable to determine

LOWER:

complete paralysis   minimal effort against gravity     some effort against gravity (+)drift

no drift (good motor function)unable to determine
LT-SENSORY : pain touch and vibration were normal     pain touch and vibration were abnormal    constructional apraxia

RT-SENSORY : pain touch and vibration were normal    pain touch were abnormal    no constructional apraxia constructional apraxia
CEREBELLAR

RT intention tremor    Lt intention tremor     unable

Rt dysdiadochokinesis    Lt dysdiadochokinesis

normal heel-to-shin and finger-to-nose exam
EXTINCTION AND INATTENTION

no abnormalities

mild to moderate

severe hemi-inattention
DISTAL MOTOR FUNCTION

normal

some extension

no voluntary extension
REFLEXES : plantar responses were flexor    plantar responses were extensor   deep tendon reflexes were symmetrical      deep tendon reflexes were asymmetrical
FRONTAL LOBE RELEASING REFLEXES :

(+) Glabellar    (-) Glabellar      (+) Snout     (-) Snout

(+) Palmar Mental     (-) Palmar Mental

(+) Gegenhalten       (-) Gegenhalten
 
 
Other abdominal findings : (+) Romberg    no Romberg
 

 

PSYCH

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Anxiety
panic attack   hyperventilation    stable anxiety
 
Depression
suicidal    non suicidal decompensate   dysthymic
 
Schizophrenia
suicidal , decompensated   non suicidal decompensated

compensated   agitated    non agitated but dysfunctional
 
Psychosis
drug induced   agitated non violent    agitated and violent
 
ETOH Withdrawal
"shakes"     agitated with the tremors    delirium tremens
 
Substance Abuse
agitated with cocaine   agitation , illicit drugs and psych history
 
Bipolar Disorder

agitated decompensated     stable

ADDITIONAL STATEMENTS ?

 

Lymphatics

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(+) regional adenopathy    
  RIGHT LEFT
     
Supraclavicular nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Tonsillar nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Submandibular nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Posterior auricular enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Pre auricular enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
     

 

 

  RIGHT LEFT
     
Epitrochlear nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Axillary nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Inguinal nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
Periumbilical nodes enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender enlarged tender miniaturespacer.gif (889 bytes)enlarged nontender
     

 

 

Skin

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VASCULAR LESIONS
spider angiomata       petechia        ecchymosis          purpura
 
SKIN LESIONS
basal cell carcinoma    atopic dermatitis    cellulitis    extensive cellulitis with lymphangitic spread  tinea capitis tinea corporis       contact dermatitis         impetigo     nonspecific exanthem
HERPES
varicella      shingles       stomatitis      genital       Ramsay-Hunt        ophthalmic
 
BLISTERING DISORDER
Pemphigus     pemphigoid      Herpetiformis      poison Ivy
 
BURNS
first degree    partial 5 %   partial 10 %   partial 15 %
partial 20 %   partial >25 %   full >10 %
Others...
Contac dermatitis    Erythema Multiforme   Steven-Johnson syndrome    Seborrheic dermatitis
ADDITIONAL STATEMENTS ?

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Last revised: October 31, 2005