Saturday, April 23, 2016

Step 2 CS: Physical exam findings in a patient with calf pain

We were practicing a case of calf pain (DVT / cellulitis) today and my friends told me that I documented the physical examination findings well, which is why I posted the note on the blog :)

Things in brackets are for reference only and I didn't type those in my 10 minutes encounter.

Pt is in NAD
VS - WNL except temp of 99.5F
Lungs - CTAB
Ext - (Notice how I use the IPROM MRSP mnemonic)
The R calf is red, warm and swollen compared to the L.
There are some cracks in the cleft between the great toe and second toe in the R side
R calf is tender to touch
(Range of motion)
ROM restricted to flexion, extension, internal rotation and external rotation in the ankle due to pain
Strength 5/5 in both legs
DTRs 2+ in both limbs
Sensations - Intact to pinprick and light touch in both ext
Pulses 2+ in dorsalis pedis artery
(Special tests)
Homans sign +ve in R leg

That's all!

Related post: IPROM MRSP mnemonic

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