JLM929
Networker
Physical Exam Patient is a 64-year-old male.
CONSTITUTIONAL: General Appearance: Healthy-appearing, NAD, and normal body habitus. Gait and Station: limp, antalgic gait, and ambulating with cane.
PSYCHIATRIC: Orientation: oriented to time, place, and person. Mood and Affect: normal mood and affect and active and alert.
GENERAL EXAM: Heart: Normal heart rate and rhythm. Lungs: Clear to auscultation.
CARDIOVASCULAR SYSTEM: Arterial Pulses Right: dorsalis pedis normal and posterior tibialis normal. Arterial Pulses Left: dorsalis pedis normal and posterior tibialis normal. Edema Right Lower Extremity: pedal 1+ and pretibial 2+. Edema Left Lower Extremity: pedal 1+ and pretibial 1+.
SKIN: Right Lower Extremity: Normal. Left Lower Extremity: ruborous and brawnish discoloration; skin grafts and muscle flaps present. Trunk: Normal skin.
CERVICAL MOTOR STRENGTH: Cervical on the Right: wrist extensors 5/5 and flexors 5/5 and deltoids 5/5, supraspinatus 5/5, infraspinatus 5/5, biceps 5/5, triceps 5/5, hand intrinsics 5/5, and digital flexors 5/5. Cervical on the Left: wrist extensors 5/5 and flexors 5/5 and deltoids 5/5, supraspinatus 5/5, infraspinatus 5/5, biceps 5/5, triceps 5/5, hand intrinsics 5/5, and digital flexors 5/5.
THORACIC SPINE EXAM: Inspection: normal alignment.
LUMBAR SPINE EXAM: Inspection: normal lordosis, iliac crests are level. No deformity.. Paraspinal Muscle Palpation on the Right: no significant focal tenderness. Paraspinal Muscle Palpation on the Left: no significant focal tenderness. Bony Palpation of the Lumbar Spine: no focal tenderness spinous process or iliac crest. Lumbar Active Range of Motion: pain during flexion and extension, pain lateral bend to the right and the left, limited in all planes due to guarding and apparent discomfort, and appropriate for age and without complaints of pain. Right Hip Exam: full range of motion without pain and no tenderness over the greater trochanter. Left Hip Exam: full range of motion without pain and no tenderness over the greater trochanter. Right SI Joint Exam: no tenderness over PSIS or SI joint and Patrick Fabere test negative. Left SI Joint Exam: no tenderness over PSIS or SI joint and Patrick Fabere test negative.
LUMBAR MOTOR STRENGTH: Lumbar on the Right: ankle dorsiflexors 4+/5 and evertors 4/5, EHL 4/5, ankle invertors 5/5 and plantar flexors 5/5, and hip flexors 5/5 and knee extensors 5/5. Lumbar on the Left: ankle dorsiflexors 4/5 and evertors 4/5, EHL 4/5, ankle invertors 5/5 and plantar flexors 5/5, and hip flexors 5/5 and knee extensors 5/5.
SENSATION: Sensation on the Right: L2 normal, L3 normal, L4 normal, L5 normal, S1 normal, and normal distal lower extremities. Sensation on the Left: L2 normal, L3 normal, and normal distal lower extremities; non dermatomal sensatory deficits secondary to LLE reconstruction. Vibratory Sensation Right: normal metatarsal head and medial malleolus.
REFLEXES: Biceps Reflex Right: Normal (2). Biceps Reflex Left: Normal (2). Brachioradialis Reflex Right: Normal (2). Brachioradialis Reflex Left: normal (2). Triceps Reflex Right: normal (2). Triceps Reflex Left: Normal (2). Knee Reflex Right: hyperactive (3). Knee Reflex Left: hyperactive (3). Ankle Reflex Right: diminished (1). Ankle Reflex Left: diminished (1). Babinski Reflex Right: Plantar reflex absent. Babinski Reflex Left: Plantar reflex absent.
ADDITIONAL SPECIAL TESTS: Special Tests on the Right: supine straight leg raising test negative and seated straight leg raising test negative. Special Tests on the Left: supine straight leg raising test negative and seated straight leg raising test negative.
GENERAL EXTREMITY EXAM: Lower Extremities: Crush injury to LLE with reconstruction, muscle and skin grafts. Left femur ORIF.
Would you consider this comprehensive or detailed?
Torn with the decision.
thanks
CONSTITUTIONAL: General Appearance: Healthy-appearing, NAD, and normal body habitus. Gait and Station: limp, antalgic gait, and ambulating with cane.
PSYCHIATRIC: Orientation: oriented to time, place, and person. Mood and Affect: normal mood and affect and active and alert.
GENERAL EXAM: Heart: Normal heart rate and rhythm. Lungs: Clear to auscultation.
CARDIOVASCULAR SYSTEM: Arterial Pulses Right: dorsalis pedis normal and posterior tibialis normal. Arterial Pulses Left: dorsalis pedis normal and posterior tibialis normal. Edema Right Lower Extremity: pedal 1+ and pretibial 2+. Edema Left Lower Extremity: pedal 1+ and pretibial 1+.
SKIN: Right Lower Extremity: Normal. Left Lower Extremity: ruborous and brawnish discoloration; skin grafts and muscle flaps present. Trunk: Normal skin.
CERVICAL MOTOR STRENGTH: Cervical on the Right: wrist extensors 5/5 and flexors 5/5 and deltoids 5/5, supraspinatus 5/5, infraspinatus 5/5, biceps 5/5, triceps 5/5, hand intrinsics 5/5, and digital flexors 5/5. Cervical on the Left: wrist extensors 5/5 and flexors 5/5 and deltoids 5/5, supraspinatus 5/5, infraspinatus 5/5, biceps 5/5, triceps 5/5, hand intrinsics 5/5, and digital flexors 5/5.
THORACIC SPINE EXAM: Inspection: normal alignment.
LUMBAR SPINE EXAM: Inspection: normal lordosis, iliac crests are level. No deformity.. Paraspinal Muscle Palpation on the Right: no significant focal tenderness. Paraspinal Muscle Palpation on the Left: no significant focal tenderness. Bony Palpation of the Lumbar Spine: no focal tenderness spinous process or iliac crest. Lumbar Active Range of Motion: pain during flexion and extension, pain lateral bend to the right and the left, limited in all planes due to guarding and apparent discomfort, and appropriate for age and without complaints of pain. Right Hip Exam: full range of motion without pain and no tenderness over the greater trochanter. Left Hip Exam: full range of motion without pain and no tenderness over the greater trochanter. Right SI Joint Exam: no tenderness over PSIS or SI joint and Patrick Fabere test negative. Left SI Joint Exam: no tenderness over PSIS or SI joint and Patrick Fabere test negative.
LUMBAR MOTOR STRENGTH: Lumbar on the Right: ankle dorsiflexors 4+/5 and evertors 4/5, EHL 4/5, ankle invertors 5/5 and plantar flexors 5/5, and hip flexors 5/5 and knee extensors 5/5. Lumbar on the Left: ankle dorsiflexors 4/5 and evertors 4/5, EHL 4/5, ankle invertors 5/5 and plantar flexors 5/5, and hip flexors 5/5 and knee extensors 5/5.
SENSATION: Sensation on the Right: L2 normal, L3 normal, L4 normal, L5 normal, S1 normal, and normal distal lower extremities. Sensation on the Left: L2 normal, L3 normal, and normal distal lower extremities; non dermatomal sensatory deficits secondary to LLE reconstruction. Vibratory Sensation Right: normal metatarsal head and medial malleolus.
REFLEXES: Biceps Reflex Right: Normal (2). Biceps Reflex Left: Normal (2). Brachioradialis Reflex Right: Normal (2). Brachioradialis Reflex Left: normal (2). Triceps Reflex Right: normal (2). Triceps Reflex Left: Normal (2). Knee Reflex Right: hyperactive (3). Knee Reflex Left: hyperactive (3). Ankle Reflex Right: diminished (1). Ankle Reflex Left: diminished (1). Babinski Reflex Right: Plantar reflex absent. Babinski Reflex Left: Plantar reflex absent.
ADDITIONAL SPECIAL TESTS: Special Tests on the Right: supine straight leg raising test negative and seated straight leg raising test negative. Special Tests on the Left: supine straight leg raising test negative and seated straight leg raising test negative.
GENERAL EXTREMITY EXAM: Lower Extremities: Crush injury to LLE with reconstruction, muscle and skin grafts. Left femur ORIF.
Would you consider this comprehensive or detailed?
Torn with the decision.
thanks