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12 Cards in this Set
- Front
- Back
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How do you write up a female external exam?
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LMP
H/o abnormal pap External: female hair distribution; no masses, lesions or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. No lesions. |
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How do you document for HIV test?
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Consent obtained for Rapid Oral HIV test. Pt informed of Negative result.
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How do you document a nodule?
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1 Size
2 Shape 3 Location 4 Tenderness 5 Mobility 6 Color 7 Surrounding skin area |
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S1,S2
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S1S2
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Murmurs
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M
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How do you write up the internal exam for a female?
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Vaginal mucosa pink and moist with rugae present. No unusual odors. Profuse thick, white, curdy discharge. Cervix pink with horizontal slit, midline; no lesions or discharge.
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How do you write up a bimanual?
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Cervix smooth, firm, mobile. No cervical motion tenderness. Utrerus midline, anteverted, firm, smooth, and nontender; not enlarge. Ovaries not palpable. No adnexal tenderness.
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What else should be included in your write up for a pap smear?
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LMP
h/o abnormal pap and when |
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Write up for breasts?
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dense no discrete masses. No dc retractions. No axillary LAN
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How do you describe Seizures?
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1 Aura
2 Onset 3 Spread 4 Type of movement 5 Body parts involved 6 Pupil changes 7 Pupil Reactivity 8 Duration 9 loss/ LOC 10 Incontinence 11 Behavioral and neurological changes after cessation of seizure activity |
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What tests are indicated for all new onset seizures
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EEG, CT, MRI of head
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Which test is most helpful in determining seizure classification?
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EEG
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