PHYSICAL EXAM:
GENERAL: This is a pleasant, cooperative, elderly Hispanic female, who is alert, oriented, and in mild distress due to back pain.
VITAL SIGNS: Her blood pressure is 150/66, pulse is 82, and respirations are 22. She is afebrile at 97.2.
HEENT: Normocephalic and atraumatic. She had a nasal cannula in place.
LUNGS: She has decreased breath sounds at the bases with poor air movement, but she has good air movement at the upper lobes. There are no wheezes or rales noted.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Normoactive bowel sounds.
EXTREMITIES: She has diminished range of motion throughout and can only flex to about 20 degrees from a supine position. She has peripheral pulses, which are intact and her toes are pink and warm. She has no clubbing, clonus, or any edema. Homans sign is negative and she has no palpable cords.
PHYSICAL EXAMINATION:
GENERAL: This is an elderly, thin, frail (XX)-year-old female. She is in no apparent distress. She is alert and oriented x3, is comfortable, sitting on bed. She is extremely hard of hearing.
HEENT: Sclerae are clear. Conjunctivae pink. Oropharynx is clear. Mucous membranes are dry.
NECK: Supple. No lymphadenopathy.
CHEST: Clear to auscultation bilaterally, anteriorly.
HEART: Regular rate and rhythm. Normal S1 and S2. No murmur is appreciated.
ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are present. There is no hepatosplenomegaly or masses noted. She does have surgical scars. She does have a PEG tube in place, which is intact.
EXTREMITIES: No clubbing, cyanosis, or edema. Significant muscle wasting.
PHYSICAL EXAM:
GENERAL: On examination, the patient is not responsive to verbal stimuli.
VITAL SIGNS: Pulse 98, blood pressure 96/54, respiration 22, temperature 98.8 degrees Fahrenheit.
HEENT: No JVD. No carotid bruit. No lymphadenopathy.
NECK: Supple. No engorged neck veins.
LUNGS: Bilaterally clear to auscultation. Decreased air entry bilaterally at the bases, most likely secondary to decreased effort.
HEART: Both heart sounds normally audible. No murmurs. No thrills.
ABDOMEN: Soft. Nontender. Bowel sounds positive. No organomegaly. The patient shows diffuse tenderness over the abdomen. However, abdomen is soft and there is no guarding or rigidity.
EXTREMITIES: No edema or cyanosis.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 96.4, pulse 58, respirations 20, blood pressure 168/84, height 5 feet 4 inches, weight 190 pounds.
GENERAL APPEARANCE: Well-developed, well-nourished, overweight woman, in no acute distress. Her affect was normal.
HEENT: NC/AT. Pupils equally round and reactive to light and accommodation.
NECK: Without bruits.
LUNGS: Clear.
HEART: Bradycardia with a normal rhythm and without murmur.
ABDOMEN: Obese. Bowel sounds positive. Soft, nontender, and nondistended.
EXTREMITIES: No clubbing, cyanosis or edema. No calf erythema, warmth or tenderness. Peripheral pulses were strong and symmetrical. Passive range of motion was within functional limits throughout, except her left wrist was painful with all movements. The left wrist was tender to palpation. There was some swelling at the left wrist.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 98.4, blood pressure 128/62, pulse 68, respiratory rate 22, 94% pulse oximetry reading.
GENERAL: Alert, in no distress. The patient is weak overall.
EYES: Anicteric sclerae, pale conjunctivae.
HEENT: Moist mucosa. No oropharyngeal lesion noted.
NECK: Supple in appearance. No thyromegaly appreciated.
LYMPH: No adenopathy peripherally.
CHEST: Symmetrical movement. Decreased breath sounds. Poor inspiratory effort. Bibasilar crackles.
HEART: S1, S2 present. Distant heart sounds noted.
ABDOMEN: Soft, obese, and nontender. No organomegaly appreciated.
EXTREMITIES: No edema or cyanosis.
SKIN: Mottled. No new ecchymosis noted. No petechiae present.
NEUROLOGIC: Alert and oriented. He has appropriate response.
MUSCULOSKELETAL: He is able to move his extremities.
PHYSICAL EXAM:
GENERAL: Well-developed, well-nourished Hispanic female, in no acute distress.
VITAL SIGNS: Temperature 98.4, pulse rate 80, respiratory rate 18, blood pressure 142/64.
HEENT: No evidence of trauma. PERRLA. Disks sharp bilaterally. Bilateral arcus senilis noted. TMs clear. Throat clear.
NECK: Supple, no bruits, no JVD, no HJR, no thyromegaly.
CHEST: Lungs clear bilaterally.
CARDIAC: Regular rate and rhythm, no S3, murmur or JVD.
ABDOMEN: Soft, nontender, obese. No organomegaly, normal bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Awake, answering only a few questions appropriately, but is moving all four extremities with power of 5/5 in all four extremities.
PHYSICAL EXAMINATION:
GENERAL: She is awake, in no acute distress. Afebrile.
VITAL SIGNS: Temperature 97.6, pulse 64, respirations 20, blood pressure 108/48. Height 156 cm. Weight 66 kg.
HEENT: Eyes: No icterus. No petechiae. Oropharynx is clear. On exam of her ears, the right auricle has a small erythematous and scaly lesion of about 0.6 mm without drainage. The right ear canal has plaques and unable to visualize tympanic membrane. The right mastoid without erythema, no fluctuance, no tenderness. The left auricle is without lesions. The left ear canal is clean, no erythema. The tympanic membrane is normal. Left mastoid without erythema, fluctuance or tenderness.
NECK: Supple. No lymphadenopathy.
CHEST: Decreased air entry at bases. No use of accessory muscles.
HEART: S1, S2 regular. No murmurs.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds present.
SKIN: Without rashes.
MUSCULOSKELETAL: No joint swelling or erythema.
EXTREMITIES: No erythema or drainage. No swelling.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 154/94, pulse 56, respirations 18, temperature 98.2, pulse oximetry 98% on room air.
HEENT: Head is normocephalic and atraumatic. TMs are clear. Pupils are equal and reactive to light. The patient has an obvious small lesion in his left eye just lateral to his pupil. On eye exam, the patient does not seem to have any foreign body. His cornea is very injected and the lesion is small, approximately 2-3 mm in diameter.
NECK: No lymphadenopathy. No thyromegaly.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nondistended, nontender.
PHYSICAL EXAMINATION: General Appearance: Well-developed, well-nourished, male/female, in no acute distress. Vital signs:
HEENT: Normocephalic, atraumatic. No scleral icterus. Pupils are equal, round and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth: Good dentition, no lesions. Tympanic membranes are clear. Neck: Supple. Trachea midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness. Chest: Symmetric. Nontender to palpation. Lungs: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi or rales. Heart: Regular rate and rhythm, normal S1/S2. No murmurs, gallops or rubs. Breasts: Symmetrical. No skin or nipple retractions. No nipple discharges or masses. Abdomen: Soft, flat and benign. No mass, tenderness, guarding or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass. Genitourinary (Male): The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent and clear. The testicles are descended bilaterally without mass or tenderness. The epididymis and cords are normal. The perineum is normal. Rectal (Male): Normal sphincter tone. No masses. Prostate is smooth, nontender and without nodules or fluctuance. Genitourinary (Female): External genitalia normal. Vagina and cervix without lesions or masses. Uterus normal. Adnexa negative for mass or tenderness. Urethral meatus normal. Perineum and anus normal. Rectal (Female): Normal sphincter tone. No masses or tenderness. Extremities: No cyanosis, clubbing or edema. Neurologic: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II-XII intact. Deep tendon reflexes are intact. Psychiatric: Awake, alert and oriented x3. Recent and remote memory is intact. Appropriate mood and affect. Skin: Warm, dry and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Lymphatics: No cervical, axillary or groin adenopathy is noted.
PHYSICAL EXAM:
GENERAL APPEARANCE: The patient is awake, alert and oriented. Speech is normal.
VITAL SIGNS: BP (value). Pulse (value). Respirations (value). Temperature (value).
HEENT: Pupils are equal and react to light. There is no subconjunctival hemorrhage. There is no icterus. Extraocular movements look normal. Both ears are normal. There is no discharge noted. The skin is warm and dry. There is no epistaxis. There is no head trauma. Cranial nerves are normal. Oral cavity looks normal.
NECK: Jugular venous pressure is not raised. Carotid pulses are palpable. Thyroid is of normal size. There is no nuchal spasm or meningeal irritation sign.
RESPIRATORY: Trachea is centrally located. Air entry is equal and present on both sides. No rales or rhonchi.
CARDIOVASCULAR: PMI is in the fifth intercostal space in the left mid clavicle line. S1/S2 well heard. There is no gallop or murmur. Rate and rhythm look normal.
ABDOMEN: Soft and supple. There is no guarding or rigidity. Peristalsis looks normal. Renal angles are clear at this time.
EXTREMITIES: No phlebitis. Extremities look normal.
NEUROLOGIC: The patient is moving all 4 limbs without any focal neurological deficits. Reflexes are 2+, and plantars are flexor. Motor power is equal and present on both sides, 5/5. There is no involuntary movement.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: Well-developed, well-nourished.
VITAL SIGNS: BP (value). Pulse (value). Respirations (value). Temperature (value).
HEENT: Normocephalic. Pupils are equal and reactive to light and accommodation. Extraocular movements are within normal limits. Pharynx: No exudates or erythema.
NECK: Supple, nontender. No masses or enlarged thyroid.
LUNGS: Clear to auscultation.
HEART: Regular rate. No murmur or gallop.
ABDOMEN: Soft, nontender. No masses or organomegaly.
BREASTS & RECTAL: Not indicated.
EXTREMITIES: Right/Left knee: Range of motion is full. There is no instability to varus or valgus stress in flexion or extension. Anterior and posterior drawer tests are negative. Lachman’s, pivot shift, McMurray’s and Apley’s tests are negative. Examination of the remainder of the upper and lower extremities is otherwise unremarkable.
NEUROLOGIC: Reveals no sensory or motor deficits.
PHYSICAL EXAM:
GENERAL APPEARANCE: Well-developed, well-nourished female/male in no acute distress.
VITAL SIGNS: BP (value). Pulse (value). Respirations (value). Temperature (value).
HEENT: Ears: There is no evidence of any external masses or lesions noted. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and moist. Septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good.
NECK: Supple. Trachea is midline. There is no jugular venous distention noted. There are no carotid bruits noted. There are no palpable masses.
LUNGS: Clear to auscultation bilaterally. There are no crackles, wheezes or rhonchi noted. There is no crepitus on palpation.
HEART: Regular rate and rhythm, S1/S2. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation.
ABDOMEN: Soft, nontender. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia.
LYMPHATICS: There is no inguinal, axillary, supraclavicular or cervical adenopathy noted.
SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor.
MUSCULOSKELETAL: Gait is coordinated and smooth. There is no clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves II-XII are grossly intact. Sensation to light touch is intact bilaterally.
PSYCHIATRIC: The patient is alert and oriented to person, place and time. There is no apparent mood disorder.
PHYSICAL EXAM: Examination reveals the patient to be alert, oriented and cooperative. The radial, superficial temporal and carotid pulses are palpable and equal. No bruits are heard in the head and neck. Mental status is intact in all 4 spheres. Pupils are equal, round and react to light. Extraocular movements are full. Fundi are benign. There is no field cut to gross confrontation. There is no facial asymmetry. The tongue protrudes to the midline. The palate moves up in the midline. There is normal tone, bulk and power in all extremities. Coordination and gait are intact. Romberg is negative. Sensory exam: All modalities are intact. Deep tendon reflexes are brisk and equal throughout. Plantar reflexes are flexor bilaterally. Head, ears, eyes nose and throat are normal. Neck is supple. There is no thyromegaly. Chest: Lungs are clear to auscultation and percussion. Cardiac rhythm is regular. There are no murmurs, gallops or rubs. Abdomen is soft and nontender. There is no organomegaly. Extremities show good pulses and no edema.
PHYSICAL EXAM:
GENERAL: The patient is a well-developed, well-nourished female.
VITAL SIGNS: Temperature 97.6, pulse 84, respirations 22, blood pressure 188/92 decreased to 148/80, pulse oximetry 96% on room air which is normal, weight 72 kg.
HEENT: Normocephalic, atraumatic. Extraocular movements intact. Pupils equal, round and reactive to light. Negative for hemotympanum, Battle sign, raccoon eyes. Facial buttresses are stable. Occlusion intact.
NECK: C-spine nontender, negative for crepitus. Trachea midline.
HEART: Regular rate and rhythm without murmur.
LUNGS: Clear to auscultation and percussion. Breath sounds equal. Negative for wheezes, rhonchi, crackles or stridor.
ABDOMEN: Soft, nontender. Positive bowel sounds. Negative for palpable masses, hepatosplenomegaly, costovertebral angle tenderness, peritoneal signs or guarding.
EXTREMITIES: Atraumatic. Negative cyanosis, clubbing or edema. Radial artery and dorsalis pedis pulses 3+ to palpation, bilateral upper and lower extremities.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 114/74, pulse 76, respiratory rate 20, temperature 98.6, pulse oximetry is 96% on room air.
GENERAL: The patient is alert and oriented x 3, in no acute distress.
HEENT: Pupils are equal, round and reactive to light. Extraocular movements are intact. Oropharynx is clear. Mucous membranes are moist. No hemotympanum. No Battle sign. No raccoon eye. No otorrhea. No rhinorrhea. No nasal septal hematoma. Orbits, mid face, mandible and dentition are atraumatic, but the patient does have tenderness over the nasal bones and nasal deviation towards the right.
NECK: Supple, nontender to palpation, no lymphadenopathy, no masses, no JVD, no carotid bruits, no meningismus. C-spine is nontender to palpation. Trachea is in the midline. No subcutaneous crepitus. No hematoma overlying the great vessels.
CHEST: Clear to auscultation bilaterally. No evidence of trauma.
CARDIAC: Regular rate and rhythm. No murmurs, rubs, or gallops.
ABDOMEN: Bowel sounds are present. The belly is soft, nontender, nondistended. No masses, no hernias, no rebound, no guarding.
BACK: No CVAT. T and LS spine nontender to palpation.
EXTREMITIES: Distal pulses 2+ bilaterally. No clubbing, cyanosis or edema. Pelvis is stable to rock. Negative log roll bilaterally. The patient has a few scrapes over his knuckles on the left hand, but otherwise, his left hand is atraumatic and nontender. He has tenderness and edema overlying his fourth metacarpal. He has full range of motion of the wrist without pain or tenderness. Right radial pulse is 2+. Right radial, ulnar and median nerve motor and sensory functions are intact. FDS, FDP and extensor tendon flexion are intact. There is no scissoring of the pinkie finger, has a normal cascade with no evidence of rotational deviation.
SKIN: No rash, no petechiae, no purpura, no jaundice.
PSYCH: Normal mood, normal affect.
NEUROLOGIC: Alert and oriented x 3, normal mental status, cranial nerves II through XII intact, strength 5/5 bilaterally throughout. Station and gait within normal limits.
PHYSICAL EXAM: VITAL SIGNS: Afebrile. Pulse 80, blood pressure 120/76, weight 139 pounds. GENERAL: No apparent distress. Pleasant Hispanic female. HEENT: Atraumatic. Extraocular muscles are intact. OROPHARYNX: Clear. Dentition is intact. Turbinates are pink and moist. NECK: She has decreased range of motion in flexion to 60 degrees, side bending about 45 degrees both sides, rotations to 65 to 70 degrees both sides and certainly a little bit limited. HEART: Regular rhythm. No murmurs. LUNGS: Clear to auscultation. No wheeze. Unlabored respirations. ABDOMEN: Soft, nontender, and nondistended. No hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: Warm and dry. No rashes. MUSCULOSKELETAL: She has some loss of cervical lordosis. She has tenderness over the rhomboid musculature on the right shoulder, more than left. NEUROLOGIC: She has subjective decreased sensation to the fourth and fifth digit on the right hand. She has muscle strength 4+/5 on the right upper extremity compared to the left upper extremity. Deep tendon reflexes are symmetric, 2/4 to the upper extremities bilaterally.
PHYSICAL EXAM: VITAL SIGNS: Blood pressure 124/82, pulse 72, and respirations 18. GENERAL: In no distress. Alert and oriented. Normocephalic. HEENT: PERRL. Conjunctiva without injection. Eyelids normal. EOMI. Pharynx without exudates. Lips smooth without lesions. Dentition normal. NECK: Supple, no rigidity, no cervical or supraclavicular adenopathy, no thyromegaly or thyroid nodules. No carotid bruits noted. CHEST: Unlabored respirations. Clear to auscultation. No wheezes, rales or rhonchi. HEART: RRR, normal S1 and S2, no S3 or S4, no murmurs or rubs are heard. ABDOMEN: Soft, NT, ND, no hepato or splenomegaly. EXTREMITIES: No clubbing, cyanosis or edema, full range of motion of upper and lower extremities. Gait normal. Dorsalis pedis and posterior tibial pulses 2/4 bilaterally, nails unremarkable in digits. NEUROLOGICAL: Motor exam 5/5 in upper and lower extremity. CN II-XII intact. BACK: No obvious abnormalities, normal to palpation without pain. RECTAL: NA. GENITAL: NA. SKIN: Warm to touch, no rashes or nevi.
PHYSICAL EXAM: VITAL SIGNS: Afebrile. Pulse 84, blood pressure 136/84, weight 220 pounds. He is 67-1/2 inches tall giving him a BMI of 34. GENERAL: No apparent distress. Pleasant, awake, alert and oriented x3, morbidly obese Hispanic male. HEENT: Atraumatic. Extraocular muscles are intact. OROPHARYNX: Clear. Dentition is intact. Turbinates are pink and moist. NECK: Supple without anterior cervical or supraclavicular adenopathy. No JVD, bruits or thyromegaly. HEART: Regular rate and rhythm without murmurs, rubs, gallops or thrills. LUNGS: Clear to auscultation. No wheezes, rales, rhonchi, unlabored respirations. ABDOMEN: Soft, nontender and nondistended. No hepatosplenomegaly. He had a large umbilical hernia that is easily reducible without pain. EXTREMITIES: No clubbing, cyanosis, no edema. 2+ dorsalis pedis pulses and posterior tibial pulses bilaterally. PSYCHIATRIC: Affect is appropriate. Mood is not depressed. No flight of ideas, tangential thoughts or pressured speech. RECTAL: Good sphincter tone. No external hemorrhoids. Prostate is symmetric without enlargement. He has guaiac heme-positive stools, brown in the vault. No rectal masses could be appreciated.
PHYSICAL EXAMINATION: GENERAL: She is a fatigued-appearing female. Awake, alert and oriented x3, somewhat diaphoretic appearing. HEENT: Atraumatic. Extraocular muscles are intact. OROPHARYNX: Cobblestoned. Dentition is intact. She does have an ulcer to the soft palate midline. Her turbinates are erythematous. Her right tympanic membrane is cloudy and boggy. NECK: Supple. She has submandibular adenopathy, both, bilaterally. No supraclavicular adenopathy. No JVD or bruits. HEART: Regular rate and rhythm. No murmurs. LUNGS: Clear to auscultation. No wheeze. Unlabored respirations. ABDOMEN: Soft, nondistended, and nontender. No hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. SKIN: Warm and dry. No rashes. NEUROLOGIC: Cranial nerves are intact. Sensation is intact. Deep tendon reflexes 2/4 in the lower extremities.
