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12 Cards in this Set

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How do you write up a female external exam?
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.
How do you document for HIV test?
Consent obtained for Rapid Oral HIV test. Pt informed of Negative result.
How do you document a nodule?
1 Size
2 Shape
3 Location
4 Tenderness
5 Mobility
6 Color
7 Surrounding skin area
S1,S2
S1S2
Murmurs
M
How do you write up the internal exam for a female?
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.
How do you write up a bimanual?
Cervix smooth, firm, mobile. No cervical motion tenderness. Utrerus midline, anteverted, firm, smooth, and nontender; not enlarge. Ovaries not palpable. No adnexal tenderness.
What else should be included in your write up for a pap smear?
LMP
h/o abnormal pap and when
Write up for breasts?
dense no discrete masses. No dc retractions. No axillary LAN
How do you describe Seizures?
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
What tests are indicated for all new onset seizures
EEG, CT, MRI of head
Which test is most helpful in determining seizure classification?
EEG