Summaries Flashcards
Cardio
Today I performed a CV exam on…who was comfortable at rest and did not report any pain
Upon examination there were no peripheral stigmata of cardiac pathology
The pulse was…
On palpation there were no heaves + thrills, and no evidence of cardiomegaly
On auscultation both heart sounds were present with no added sounds
Resp
Today I performed a respiratory exam on…who was comfortable at rest and was not using their accessory muscles to aid breathing
On examination, there were no peripheral stigmata of respiratory pathology
The pulse was… and RR was…
There was no evidence of tremor, there was symmetrical chest expansion and no evidence of mediastinal shift or hyperinflation
On percussion, all fields were resonant with vesicular breath sounds and no added sounds
Abdominal
Today I performed on abdominal exam on…who was comfortable at rest and reported no pain
There were no peripheral stigmata of gastrointestinal pathology
There was no tremor of asteristick nature
The abdomen was soft non-tender with no evidence of organmegally
Bowel sounds were present and normal
GALS
Today I performed a GALS screening on…who was comfortable at rest
There was a normal appearance of Gait, Arms, Legs and Spine and full ROM in all modalities tested
MSK (Spine/Hips/Knee/Ankle/Hands)
Today I performed … MSK exam on … who was comfortable at rest
On examination there were no abnormalities detected, the patient had normal gait, no tenderness, full ROM and special tests were negative
Hands: dermatomes in tact
Cranial nerves
Today I performed an examination of … CN’s who appeared well at rest
Cranial nerves … were normal and special tests were negative
Upper limb
Today I performed an upper limb neurological on … who was comfortable at rest
There were no abnormalities in posture
There was no muscle wasting or fasciculations
Pronator drift was negative
Tone was normal
Power was 5/5 bilaterally and throughout
Reflexes were normal and present bilaterally
Dermatomes were in tact
Coordination was normal
Lower limb
Today I performed an lower limb neurological on … who was comfortable at rest
There were no abnormalities in posture
There was no muscle wasting or fasciculations
Romberg’s test was negative
Gait was normal with both dorsiflexion and plantarflexion in tact
Tone was normal
Power was 5/5 in all muscle groups bilaterally
Reflexes were normal and present bilaterally
Dermatomes were in tact + sensation normal in all modalities tested
Coordination was normal
Both plantars were downward facing
Cerebellar
Today I performed a cerebellar exam on … who was comfortable at rest
Romberg’s test was negative
There was no evidence of ataxic gait or truncal ataxia
Coordination was normal
There no evidence of nystagmus or tremor
Tone was normal throughout
Thyroid
Today I performed a thyroid exam on …
On general inspection, they seemed comfortable at rest
On examination, there were no peripheral stigmata of thyroid pathology
The pulse was …
There was no evidence of tremor
No evidence of thyroid eye disease, goitre or other swelling
On percussion, there was no evidence of retrosternal goitre
No evidence of bruits
Diabetic foot
Today I performed a diabetic foot exam on … who was comfortable at rest
There were no abnormalities detected, gait was normal
Neurovascular assessment of both feet were normal
Sensation was intact
Peripheral vascular
No peripheral stigmata of vascular disease
Pulses were present bilaterally in the upper and lower limbs at …
AA was palpable
Sensation of lower limb was intact
