Selected Shorthand Exams

[shorthand name="cerebellex"]No tremor, dysmetria, dysdiadachokinesia, or ataxia[/shorthand][shorthand name="bpvex"]Dix-Hallpike was performed to evaluate both left and right vestibular systems sequentially.  Left ear dependent induced nystagmus and vertigo with left sided recumbancy with head turned and extended 45 degrees.
Nystagmus was moderate in degree.[shorthand name="breastex"]BREASTS: no dominant mass by palpation, no fibrocystic changes, no axillary adenopathy, no breast tenderness.[/shorthand][shorthand name="conjex"]General  Appearance: NAD
Visual acuity: per nursing documentation
Left eye exam: normal, PERRL, EOMI, no conjunctival injection or erythema, no mattering, no excessive tearing, eyelids normal, fundus normal. 
Right eye exam: normal, PERRL, EOMI, no conjunctival injection or erythema, no mattering, no excessive tearing, eyelids normal, fundus normal.[/shorthand][shorthand name="contusionex"]General Appearance: NAD, ambulatory
Skin: no bruising, swelling, eccymosis, or hematoma
Joints: normal range of motion, ligaments stable
no swelling/effusion noted
Neurovascular exam: normal capillary refill[/shorthand][shorthand name="cvex"]HEART: RR, no murmur/click, S3 S4, HJR or carotid bruit
VESSELS:  No varicosities.  Pulses are normal and symmetrical without bruits.[/shorthand][shorthand name="abdex"]ABDOMEN:  Auscultation showed normal bwoel sounds.  Percussion and palpation - abdomen is soft, non-tender without masses, hepatosplenomegaly or abnormal pulsation.  There is no guarding or rebound tenderness[/shorthand]
[shorthand name="backex"]BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm[/shorthand]
[shorthand name="entex"]ENT: 
Ear: External auditory canals and tympanic membranes clear, with hearing grossly intact.
Nose: without obstruction or discharge. 
Oral cavity and pharynx: without inflammation, swelling, exudate or lesions. 
Teeth and gums in good general condition.[/shorthand][shorthand name="genex"]GENERAL APPEARANCE: The patient is well developed, well nourished, healthy appearing, oriented, alert, awake, cooperative and in no acute distress.[/shorthand][shorthand name="lungex"]LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.[/shorthand]
[shorthand name="neurex"]NEUROLOGICAL: Alert and oriented with grossly normal cranial nerves, sensation, motor strength, coordination and deep tendon reflexes.[/shorthand][shorthand name="rectex"]RECTAL: Good sphincter tone with no anal, perineal or rectal lesions.  Stool guiac negative.  Prostate is not tender, enlarged or nodular[/shorthand][shorthand name="skinex"]SKIN: Skin normal color, texture and turgor with no lesions or eruptions.[/shorthand][shorthand name="musclowex"]MUSCULOSKELETAL LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity.[/shorthand][checkbox memo="textarea - Hide/Show - for testing)" name="textareatest" value=""][conditional field="textareatest" condition="(textareatest).isNot('')"][textarea name="variable_1"]for testing[/textarea][/conditional]