Musculoskeletal help
Posted By: thequeen on 2009-04-21
In Reply to:
Subject: Musculoskeletal help
I am doing a musculoskeletal exam. I cannot figure out what he is saying and cannot find a list of common tests done. Does anyone have a clue?
s/l Trendellenburg's test, (s/l bactruse) test, (s/l ulise) test, (s/lserial halls) test (s/l spurring) and straight leg raising negative.
Thanks in advance.
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musculoskeletal
Subject: musculoskeletal
Thanks for your advise, but...
Yes, that is what I would put, but dictators are very specific and do not want their verbiage changed, but cannot find a correct spelling of this anywhere!
Figured out the musculoskeletal one... still looking for the other...
Subject: Figured out the musculoskeletal one... still looking for the other...
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
Musculoskeletal/Neurologic
Subject: Musculoskeletal/Neurologic
You need to head it the way I did in the subject above...
Musculoskeletal Exam
Subject: Musculoskeletal Exam
Does this make sense to anyone? Active range of motion of the left knee is approximately 0 to 100?
Musculoskeletal Exam
Subject: Musculoskeletal Exam
There are no [s/l dermaternal?] changes noted in upper and lower extremities.
Musculoskeletal exam
Subject: Musculoskeletal exam
Sensation is intact for the s/l fil-a-mon test.
It is Amrix, a musculoskeletal relaxant- nm
Subject: It is Amrix, a musculoskeletal relaxant- nm
xx
Roxitan is correct....musculoskeletal and
Subject: Roxitan is correct....musculoskeletal and
xx
I'd say positive for musculoskeletal back pain.
Subject: I'd say positive for musculoskeletal back pain.
s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
Subject: s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
x
Musculoskeletal exam: The patient has good s/l RAM.
Subject: Musculoskeletal exam: The patient has good s/l RAM.
She says this twice. Clearly not sounding like range of motion. Thanks for any help!
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