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Category: Templates

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.   What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:   Eyes – is the child attentive with the eyes Motor – is the child appropriately active/reactive Verbal –…

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LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

LUMBAR SPINE NEUROLOGICAL EXAMINATION TEMPLATE

The neurological examination is relative to the pathology you are investigating. This should not be used in a cut and paste fashion but rather for reference.   MOTOR Hip flexion “pull your knee to your chest” (L2/3) 5/5 Hip adduction “pull your knees into each other” (L2/3) 5/5 Hip abduction “pull your knees apart” (L4/5/S1) 5/5 Hip extension “pull your thigh back” (L4/5) 5/5 Knee extension “hold your knee straight” (L3/4) 5/5 Knee flexion “pull your heel to your bottom”…

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PENETRATING NECK TRAUMA REQUIRES DETAILED EXAMINATION

PENETRATING NECK TRAUMA REQUIRES DETAILED EXAMINATION

A patient presents with a stab wound to the neck. You examine the wound and see a 1 cm laceration. The patient reports no other symptoms. How can we best identify injuries?   Through the neck run longitudinal blood vessels, nerves, as well as organs of the respiratory and gastrointestinal systems. The mechanism is important – what is the direction of the wound tract?   Below is a template of a thorough examination of penetrating neck trauma, with more detail…

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COMA NEUROLOGIC EXAM TEMPLATE

COMA NEUROLOGIC EXAM TEMPLATE

An example of a comprehensive coma exam in a patient with psychogenic coma:   General: -description – lying supine, well-dressed -breathing pattern – normal -breath odor – normal Head atraumatic normocephalic Eyes: -eyes midline and conjugate without deviation -pupils 2mm, equally reactive -eyes squint to bright light -fundoscopy – unable to perform due to eye movement -purposeful movements detected Oropharynx – mucus membranes moist Neck – no meningismus Chest cta bilat Heart rrr no mrg Abd soft, nt, no om…

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EYE TEMPLATE

EYE TEMPLATE

Acuity: Extraocular movements: intact and painless Visual fields: intact Lids/Lacrim: nl, no edema Conjunctivae/sclera: nl, no injection Cornea: clear, no ulcers, no uptake of fluorescein Anterior chamber: clear Pupils: equally round, reactive to light, no direct or consensual photophobia. No afferent pupillary defect Fundoscopy: intact red reflex, sharp disc Intraocular pressure:

NEONATAL NEUROLOGIC EXAMINATION

NEONATAL NEUROLOGIC EXAMINATION

Here is an outline of the neonatal neurologic examination followed by a listing of some reflexes that might be of value in demonstrating intact neurologic function.   GENERAL OBSERVATION/BEHAVIOR   CRANIAL NERVES CN II – responds to light CN III/IV/VI – vestibulo-ocular reflexes intact to cardinal directions of gaze CN V – rooting reflex intact CN VII – facial symmetry during crying CN VIII – responds to sound CN IX/X/XII – normal sucking CN XI – sternocleidomastoid movement noted  …

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HAND MUSCLE AND TENDON CHART

HAND MUSCLE AND TENDON CHART

Movement Muscle Nerve Nerve root Remarks Thumb flexion IP FPL (flexor pollicis longus) Median (AIN branch) C8, T1 Finger flexion DIP 2/3 FDP (flexor digitorum profundus) Median (AIN branch) C8 In forearm the FDP is superficial to the FDS Finger flexion DIP 3/4/5 FDP (flexor digitorum profundus) Ulnar C8 Digits 3,4,5 FDP are banded together.  Flexion of one flexes all. Hold the rest of the digit in extension during the exam PIP flexion FDS (flexor digitorum superficialis) Median C7 Because…

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HAND EXAMINATION TEMPLATE: FUNCTIONAL ANATOMY

HAND EXAMINATION TEMPLATE: FUNCTIONAL ANATOMY

  VASCULAR   Palpation – “extremity warm”   Color – “healthy pink”   Pulses – radial pulse normal   Capillary refill < 2 seconds       NEUROLOGIC – MOTOR (AND MUSCULOTENDINOUS)   THUMB   FPL distal thumb flexion 5/5   ADP thumb apposition 5/5   APB palmar abduction 5/5   APL radial abduction 5/5   EPL thumb dorsal extension 5/5       FLEXORS   FDP distal phalanx flexion 5/5   FDS proximal phalanx flexion 5/5 (with DIP and…

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TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION

TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION

  FUNCTIONAL ANATOMY TEMPLATE: NEUROLOGICAL MENTAL STATUS EXAMINATION   Having a structured, systematic approach to the neurological mental status examination can greatly improve our diagnostic acumen.  Because this examination is long and complex, it helps to have a template. Unlike the mini-mental status examination, this template is organized by functional anatomy.     GLOBAL BRAIN FUNCTION Arousal – alert (lethargy = drifts off, obtunded = difficult to arouse, stupor = requires constant vigorous stimulation, coma = unarousable.  If you can’t…

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TEMPLATE: THE PSYCHIATRY EXAM

TEMPLATE: THE PSYCHIATRY EXAM

Here is a template that helps one document encounters with psychiatric overtones.  I included pertinent negatives that help prompt one to use the right terms.  These can be deleted during actual encounters.  Although I hear many express less enthusiasm for psychiatric emergencies, I believe that being able to systematically assess a patient’s psychiatric state goes a long way toward understanding the difficult patient encounter.   Arousal: Alert Attentiveness: fully attentive Appearance: well-dressed and well-groomed Attitude: cooperative, not guarded Activity: calm,…

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