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Physical therapy word

Posted By: Kristi on 2007-09-26
In Reply to:

Subject: Physical therapy word

...  and progressing to various other quad exercises to include TKEs and then s/l don tignies.  Any suggestions?


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PHYSICAL EXAMINATION: Significant findings for left lower quadrant tenderness. Blood pressure was 124/78, pulse rate of 96, and respiratory rate of 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.


I would type it this way or at least make it present tense.  On my accounts, I am required to categorize these things. 


PHYSICAL EXAMINATION:


Abdomen:  Significant findings for left lower quadrant tenderness. Vital signs:  Blood pressure 124/78, pulse rate 96, respiratory rate 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.


 


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Subject: Physical exam help?

EXAMINATION:  No costovertebral angle tenderness.  Abdomen has normal active bowel sounds in all quadrants.  It is supple.  Extremely tender left upper quadrant and going down not quite into the groin.  Difficult to check the (s/l sternal) border because of increased tenderness but the spleen may be mildly enlarged but no distinct masses felt.  I am unable to check for rebound or guarding because she is so exquisitely tender with even a very light touch.


 


ASSESSMENT:  Acute left upper quadrant pain.


s/l sternal border?  Any help would be great?