EXAM MALE abdomen
Appears stable
Alert
No meningism
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
No LkkS
Ho intact bilat
Throat: nad
Lymphadenopathy: nill
Urine dip
Scrotum/testes:
Appears stable
Alert
No meningism
No Jaccyol
Apyrexial
t:
p:
hs: normal
bp:
rr:
sats: %
wheeze: nill
crackles: nill
Abdo: snt
No LkkS
Ho intact bilat
Throat: nad
Lymphadenopathy: nill
Urine dip
Scrotum/testes:
FAST Face Arm Speech – negative
GCS: 15/15
GCS: 15/15
Alert orientated tpp.
CNS PNS intact symmetrical
Perla
EOM full rom
No nystagmus
No ataxia
Perla
EOM full rom
No nystagmus
No ataxia
#neuro: full cns pns
Fever: nill
Trauma impact injury: nill
No new or progressive neurological symptoms face arms legs,
no disturbance to cognition, vision, speech.
Fever: nill
Trauma impact injury: nill
No new or progressive neurological symptoms face arms legs,
no disturbance to cognition, vision, speech.
#neuro: CNS
Fever: nill
Trauma impact injury: nill
No new or progressive neurological symptoms face,
no disturbance to cognition, vision, speech
Fever: nill
Trauma impact injury: nill
No new or progressive neurological symptoms face,
no disturbance to cognition, vision, speech
#neuro: PNS Cervical
Fever: nill
Trauma impact injury: nill
Neck jolts or forces: Nill
Axillary swellings changes: Nill
No new or progressive neurological symptoms Upper limbs Hands,
No association with neck movements
Fever: nill
Trauma impact injury: nill
Neck jolts or forces: Nill
Axillary swellings changes: Nill
No new or progressive neurological symptoms Upper limbs Hands,
No association with neck movements
#neuro: PNS lumbosacral
Fever: nill
Trauma impact injury: nill
Excessive strenuous use: Nill
Heavy Lifting: nill
No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
Analgesia used: Nill
Posture: spinal alignment: Normal
AP Alignment: Normal cervical and lumbar lordosis
lateral Alignment: No scoliosis
Tone power reflexes symmetrical
Plantars: down going
Analgesia issued
Naproxen with ppi cover
Co-codamol with lactulose cover
Gentle heat massage mobilisation posture advise
Safety net cauda equina Urgent attention if any features
Fever: nill
Trauma impact injury: nill
Excessive strenuous use: Nill
Heavy Lifting: nill
No new or progressive neurological symptoms lower limbs or perineum,
No urinary or perianal neurological symptoms
Analgesia used: Nill
Posture: spinal alignment: Normal
AP Alignment: Normal cervical and lumbar lordosis
lateral Alignment: No scoliosis
Tone power reflexes symmetrical
Plantars: down going
Analgesia issued
Naproxen with ppi cover
Co-codamol with lactulose cover
Gentle heat massage mobilisation posture advise
Safety net cauda equina Urgent attention if any features