VITAL SIGNS: On examination, the patient had a temperature of 101.5 degrees, pulse of 83 per minute, respirations of 18 per minute and blood pressure of 143/68. The patient was saturating at 100% on room air.
GENERAL: The patient is a very pleasant lady, no evidence of distress/discomfort.
HEENT: Examination revealed no pallor, no icterus, no lymphadenopathy. The patient had oral thrush. The patient had mild erythema of posterior pharynx, otherwise moist mucous membranes.
NECK: Supple. No JVD. No rigidity.
HEART: S1 and S2 present. Systolic murmur, 2/6.
LUNGS: Bilaterally clear to auscultation.
CHEST: PermCath site, which is now status post PermCath removal. There was redness and streaking. The area was bandaged secondary to removal of PermCath.
ABDOMEN: The patient had bowel sounds present, nontender, nondistended, obese, soft, no CVA tenderness.
NEUROLOGIC: No focal neurological deficits.
EXTREMITIES: Peripheral examination revealed no pedal edema. Peripheral pulses were 2+.
PHYSICAL EXAMINATION: VITAL SIGNS: At the time of presentation, the patient’s vital signs were stable. The patient’s temperature was 98.7, pulse 92, blood pressure 149/88 and respirations 18. GENERAL: Upon physical examination, the patient was alert, awake and oriented x3 with no apparent distress. CARDIOVASCULAR: Regular. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Nontender and nondistended. Positive bowel sounds in all four quadrants. NEUROLOGIC: The patient was with full mentation and speech. Cranial nerves II through XII were grossly intact. Motor function on the left lower extremity psoas was 3/5, dorsiflexion of 3/5 and plantar flexion of 3/5. The patient also complained of some sensory deficit in the back of the left foot.
GENERAL: The patient is well developed, well nourished and in mild respiratory discomfort.
VITAL SIGNS: Pulse 97, respirations 18, blood pressure 126/82 and oxygen saturation was 88% on room air.
HEENT: Head and neck examination was normocephalic. Nares showed mild congestion. Conjunctivae were pink. Sclerae anicteric.
CHEST: Showed bilateral diffuse inspiratory and expiratory wheezing and prolonged expiratory phase.
HEART: Regular rhythm without murmurs.
ABDOMEN: Soft. Bowel sounds were positive.
EXTREMITIES: Showed no edema. Pulses were good distally.
VITAL SIGNS: His blood pressure is 142/62, respirations 19, pulse 78, temperature 96.5, saturations 98%.
GENERAL: Examination shows middle-aged man who is awake, alert and oriented. He is in no distress, sitting comfortably in bed.
HEENT: Atraumatic and normocephalic. Pupils are reactive bilaterally. I do not see any jaundice. Sclerae and conjunctivae appear normal. Ears: Externally, no infection. Oral cavity: Moist mucous membranes. No deviation of the tongue. No deviation of angle of mouth.
NECK: Supple. No JVD elevation. Trachea is midline. No lymphadenopathy or thyromegaly.
CHEST: Good bilateral air entry. No wheezes. No crackles.
CARDIOVASCULAR: S1 and S2 heard. No gallops.
ABDOMEN: Soft, nontender.
CENTRAL NERVOUS SYSTEM: Intact, no focal findings.
PERIPHERAL EXAMINATION: No edema, discoloration, cyanosis or clubbing.
PHYSICAL EXAMINATION: General: He is an obese white male. He is alert and oriented x3 and in no acute distress at this time, though he cannot lift himself to sit up. HEENT: Head is normocephalic and atraumatic. Extraocular movements intact. Neck: There is no neck vein distention or carotid bruits auscultated. Lungs: Have decreased excursions though lungs are clear to auscultation. Heart: Has a regular rate and rhythm. S1 and S2 without murmur, rub or gallop. Abdomen: Has positive bowel sounds, nontender, nondistended without hepatomegaly. Extremities: There are pulses, 1/4, in the left leg. It feels cooler than the right. There is no edema noted and venostasis markings are noted, and the patient does have difficulty sitting himself up because of his body habitus though he does move his legs and arms on command.
PHYSICAL EXAMINATION: Alert, oriented female who is anxious and in some distress. She is afebrile with a blood pressure of 186/85, pulse of 96 and regular, respiratory rate of 18 and unlabored. There was no jaundice. Her conjunctivae and eyelids were normal. She has full extraocular movements. Her oral cavity and oropharynx are unremarkable. There is no evidence of adenopathy in her head, neck or supraclavicular regions. Trachea is midline. Thyroid is not enlarged. The lungs fields are clear, symmetrical air entry. Her heart exam is normal without murmurs, rubs or bruits. There are no abdominal masses. No tenderness. No hepatosplenomegaly. She has a massively swollen left leg and poor vascular supply to the ankle and distal tibia and fibula with atrophy and redness of the tissues.
PHYSICAL EXAM: VITAL SIGNS: Temperature 98.5 degrees, pulse 91, respirations 22, and blood pressure 121/76. GENERAL: She is a young female appropriate for her age. She was lying on the stretcher comfortably. SKIN: Showed dark macular lesions on the back. HEENT: Head was normocephalic and atraumatic. Eyes: Pupils were equally round and reactive to light and accommodation. Positive for dry, white crust on the eyelids bilaterally. Supraorbital swelling bilaterally. Ears: No discharge. Canals patent. Tympanic membranes were pearly white. Nose: Patent, no polyp, no congestion of the nasal turbinates. No discharge. Upper lip showed crusted white lesions with dried blood on them and obvious swelling. Lower lip was also obviously swollen with serosanguineous discharge. The patient was unable to open the mouth. NECK: Supple. No JVD. Left posterior cervical lymphadenopathy. Lymph node of about 1 cm. CHEST: Anterior chest wall was nontender to palpation, equal expansion bilaterally. HEART: First and second heart sounds were appreciated. Regular rate and rhythm. No murmur, rales, or gallops were appreciated. LUNGS: Clear to auscultation bilaterally. No wheezing, rales, or rhonchi were appreciated. ABDOMEN: Soft, nontender, and nondistended. Bowel sounds were positive. No organomegaly was appreciated. PELVIC: Pelvic examination did not reveal any lesions like blisters or vesicles. No discharge. Pelvic examination, as per OB/GYN consult in the ER, did not reveal any abnormality. The cervix was thick and closed. No discharge was observed. MUSCULOSKELETAL: Free range of motion. No deformities. No swelling or tenderness of the joints. EXTREMITIES: No lower extremity edema. No cyanosis or clubbing. Pulses were strong and positive bilaterally both in the upper and the lower extremities. NEUROLOGIC: She was awake, alert, and oriented to time, place, and person. Cranial nerves II through XII were intact. No sensory or motor deficits were appreciated. No lesions along any dermatomes were appreciated.
PHYSICAL EXAMINATION: She is 5 feet 5 inches, 138 pounds, in no acute distress. Her blood pressure is 144/82. Pulse is 78. She is slightly anxious but well appearing and in no acute distress. Head is normocephalic and atraumatic. Sclerae anicteric. Pupils are equally round and reactive to light. Extraocular muscles are intact. Oropharynx: Clear with no edema or exudate. Tympanic membranes are patent bilaterally. Neck is supple. No lymphadenopathy or thyromegaly. Lungs are clear. She has a regular heart rate and rhythm. Normal S1 and S2. Abdomen is soft, nontender, and nondistended. Breast exam shows no masses, no asymmetry, no supraclavicular or axillary adenopathy. Extremities show no clubbing, cyanosis or edema.
VITAL SIGNS: Temperature 98.6, O2 saturation 100%, pulse 94, blood pressure 112/74. She is 5 feet 6 inches, weighs 142 pounds.
GENERAL: The patient is pleasant, in no apparent distress and looks well.
SKIN: Her skin is warm and dry.
HEENT: Pupils equal and react to light. Mucous membranes are moist. Ears: Without erythema. Posterior pharynx without erythema or exudate. Sinuses are nontender.
NODES: She has a tiny, pea-sized left posterior node present.
LUNGS: Clear without rales, rhonchi or wheezes.
SPINE: Without bony tenderness or paravertebral spasm.
HEART: S1, S2, regular rate and rhythm. Carotids without bruits.
ABDOMEN: Positive bowel sounds, soft, and nontender without HSM, without CVA tenderness. BREASTS: Medium size, round, regular. Nipples are everted. Right breast without masses or tenderness. Left breast without masses or tenderness. No discrete lumps or masses. Axillary and epitrochlear nodes are negative.
EXTREMITIES: Strength and sensation is intact to upper and lower extremities. DTRs absent upper extremities; 3+ knees, 2+ ankles. Good pedal pulses.
PHYSICAL EXAMINATION: The patient is a well-developed, well-nourished woman, in no acute distress. She has no evidence of scleral icterus. She has no evidence of supraclavicular, cervical, or axillary adenopathy bilaterally. Her pupils are equally round and reactive to light. Her extraocular movements are intact. Her neck is supple. Her mucous membranes are moist. Her lungs are clear to auscultation bilaterally. Her heart is regular rate and rhythm. She has no evidence of spinal tenderness. Her abdomen is soft and nontender without evidence of hepatosplenomegaly. Her extremities are without clubbing, cyanosis, or edema. Neurologically, she is alert and oriented x3. Her breasts are of moderate size, pendulous, and symmetric. She has a well-healed medial inframammary incision that is barely visible and does not cause any skin retraction. She has no evidence of nipple discharge, nipple retraction, or other skin changes bilaterally. I could not appreciate any concerning dominant masses in either breast.
VITAL SIGNS: On exam, the patient is afebrile. Vital signs are stable.
GENERAL: He is an alert, oriented, pleasant male in no apparent respiratory distress.
HEAD AND NECK: Exam is unremarkable.
ABDOMEN: Soft, nontender, obese, nondistended.
GENITOURINARY: Exam is significant for a normal uncircumcised penis without lesions. His testes are descended bilaterally without mass.
RECTAL: Exam is significant for normal resting and voluntary sphincter tone. His prostate is flat, firm, non-nodular, and nontender.
GENERAL: The patient is awake, alert, and appears generally well. She is in no distress.
VITAL SIGNS: Blood pressure 134/82, pulse 66, respirations 18, temperature 96.8, oxygen saturation on room air 98%.
CHEST: No respiratory distress.
CARDIAC: Rate and rhythm are normal.
EXTREMITIES: Exam of the left lower extremity reveals no obvious swelling, discoloration or deformity. There is localized tenderness to palpation over the medial femoral condyle area. There is no joint effusion appreciated. The patient is able to straight leg raise and is able to fully flex the knee with some discomfort. There is no ligamentous instability. There is no pain with range of motion of the hip or ankle. The distal neurovascular status is intact. The patient’s gait is fairly normal. She is overweight.
SKIN: Normal color and turgor without rash.
PHYSICAL EXAMINATION: The patient is a 5 feet 6 inch, 138-pound individual who stands with a level pelvis, is compensated. Paraspinal musculature is soft. No trigger point or point tenderness over the back. CVA is nontender. When asked to forward flex, she could do so cleanly to 90 degrees, side bend 5 to 10, extend 10. She had pain with side bending and extension. Trendelenburg sign is negative. Heel-toe gait is preserved. Her lower extremity motor is 5/5, foot dorsiflexion, plantarflexion, inversion, eversion, knee extension, knee flexion, hip flexion, hip abduction. Sharp-dull sensation was intact across both feet. Reflexes in knees and ankles were 1+ symmetric, side to side. She had hamstring tightness on the left at about 70 degrees and on the right at about 80 to 90. Hip and knee range of motion was full. Figure four maneuver was benign. Knee range of motion was good.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6 degrees, pulse 84, respirations 18, blood pressure 124/76, and O2 saturation 96% on room air. GENERAL: No acute distress. The patient is sitting in chair, cooperative, oriented to person and time but not to place. Unable to give good history. Able to follow commands. HEENT: Moist oral mucosa. Poor dentition. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. LUNGS: Clear to auscultation bilaterally. No wheezes appreciated. HEART: Regular rate and rhythm. No murmurs appreciated. ABDOMEN: Soft and nontender with positive bowel sounds. UPPER EXTREMITIES: Manual muscle testing shows 5/5 grip strength, elbow flexion, and elbow extension bilaterally. 2+ deep tendon reflexes bilaterally. LOWER EXTREMITIES: No calf tenderness. Positive pedal pulses.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 114/58, pulse 68, respiratory rate 20, she was afebrile at 98.4, and O2 saturation 96% on room air. GENERAL: An elderly pleasant female, looking a lot younger than her stated age. She was in no distress. HEENT: Pupils are equal and reactive. Tympanic membranes were clear. Her oropharynx had clear drainage. NECK: Supple. There was no JVD. LUNGS: Diminished breath sounds with crackles in the bases. No accessory muscle use. She had no wheezes, no rhonchi, with good airflow. She had good excursion. CARDIAC: Irregularly irregular rhythm with no obvious S3. ABDOMEN: Soft and nontender. There was no liver edge felt, no bruising. EXTREMITIES: Somewhat cool. She had trace pedal edema bilaterally. No calf tenderness. Pulses were intact. NEUROLOGIC: She moved all extremities and appeared intact.
PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 88 and irregularly irregular, temperature 100.6, pulse 106, respiratory rate 22, blood pressure 108/64, 98% saturation on 2 liters of oxygen. HEENT: Pupils are equal and reactive. Sclerae are anicteric. Oropharynx is clear. NECK: Supple. No JVD. CARDIOVASCULAR: Irregularly irregular rhythm. No S3. CHEST: Clear, slightly decreased. No crackles, no wheeze, no egophony, no accessory muscle use. ABDOMEN: Soft and nontender. There is no liver edge felt. EXTREMITIES: Show petechial areas bilaterally. The right leg is definitely larger in the calf muscle than the left. There is a reddened area on the left shin. There are no obvious cords. NEUROLOGIC: He does appear to have some decreased motor movement in the left leg, but it is minimal, 4+/5.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 116/74, heart rate 76 and irregular. HEENT: JVD is noted to the angle of the jaw at 20 degrees. NECK: Carotid pulses were 2+. No audible bruits. No subclavian bruits audible. LUNGS: Coarse and fine rales, right greater than left, with scattered wheezes and rhonchi. HEART: Sounds are diminished. Irregular rhythm. There is a soft systolic apical murmur. ABDOMEN: Somewhat distended and nontender. There is some percussible ascites. Femoral pulses were weak. No audible bruit. EXTREMITIES: Pedal pulses were weak. There was 2+ bilateral lower extremity edema with erythema bilaterally.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99 degrees, heart rate 122 beats per minute, respiratory rate 24 breaths per minute, blood pressure 172/98 mmHg, oxygen saturation 94% on 12 liters per minute high-flow nasal cannula. GENERAL: The patient is alert, responsive, in good spirits, resting fairly comfortably in bed. No impending respiratory distress is appreciated at this time. HEENT: Head is normocephalic to inspection. Pupils are reactive to light. No conjunctival redness or scleral icterus is appreciated. Hearing acuity is grossly intact. Nares are patent with dry nasal mucosa. Tongue is midline without fasciculations. Oral mucosa is dry. RESPIRATORY: The patient’s breath sounds are diminished throughout lung fields bilaterally. Bilateral inspiratory crackles are noted in mid and lower lung zones. No wheezing appreciated. CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. No S3 or S4 noted. ABDOMEN: Distended abdomen. Decreased bowel sounds. The patient’s abdomen is soft and nontender. No masses are appreciated. No bruits auscultated. EXTREMITIES: Decreased range of motion. Good pulses, 4+ lower extremity edema is appreciated. No calf tenderness. No palpable cords. BACK: No CVA or spinal tenderness. LYMPH NODES: No lymphadenopathy noted in head and neck regions. SKIN: Warm and dry. No visible erythema, rashes or cyanosis. NEUROLOGIC: The patient is alert and oriented to person, place, and time. Cranial nerves II through XII are grossly intact. Sensation is normal. Strength is 4/5, motor, in all extremities. Normal mood and normal affect are noted. No focal neurologic deficits are appreciated at this time.
PHYSICAL EXAMINATION: GENERAL: The patient is intubated and unresponsive, deeply sedated. NECK: Jugular venous pressure not appreciated. There is a right carotid scar secondary to endarterectomy. There is a left carotid bruit. CHEST: Revealed depressed breath sounds with expiratory wheezing and crackles, mostly on the right side. CARDIOVASCULAR: Revealed probably a normally located point of maximal impulse with regular heart rate, tachycardia. There is a 2/6 systolic murmur at the left lower sternal border radiating to the apex. ABDOMEN: Soft. There are bowel sounds. There is an abdominal surgical scar without any inflammatory signs. EXTREMITIES: Revealed no edema. They are dry, cold. Pulses are felt only with Doppler at the DT and PT. There are good femoral bilateral pulses. There are chronic pigmentation changes. There are multiple small superficial ulcerations.
PHYSICAL EXAMINATION: GENERAL: The patient is in no distress. He is hard of hearing. VITAL SIGNS: Pulse rate 72, afebrile. HEENT: Pupils equal, round, and reactive to light. Mucosa moist. NECK: Reveals no significant JVD or carotid bruits. LUNGS: Clear. HEART: Normal. Mildly displaced PMI with RV lift. Second sound was split and moves. There is an S4, no S3. There is a systolic ejection murmur peaking early in systole at the base and a 1 to 2/6 AI at the upper sternal border. There is no S3. ABDOMEN: No palpable nodes. No infraumbilical bruit. EXTREMITIES: Upper extremity pulses are equal. There are normal femoral foot pulses without peripheral edema. SKIN: No rash. MUSCULOSKELETAL: No acute abnormalities.
PHYSICAL EXAMINATION: VITAL SIGNS: Height 5 feet 6 inches. Weight 366. Blood pressure 162/68, heart rate 84, and respirations 16. GENERAL APPEARANCE: Morbidly obese male with a lazy eye, wearing glasses, in no acute distress, walks without assistance and follows verbal commands with perfect responses. HEENT: Normocephalic and atraumatic. Extraocular movements are intact without nystagmus. A slight left lazy eye. Pupils are equally round and reactive to light and accommodation. No conjunctival erythema. Anicteric sclerae. Mouth: Moist and pink. No lesions. Small oropharynx. Positive rise of uvula on phonation. NECK: No carotid bruits. No cervical or supraclavicular adenopathy noted. No JVD. No thyromegaly. HEART: Regular rate and rhythm. No murmurs, rubs, or gallops. S1and S2 of appropriate intensity. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Morbidly obese distended abdomen, very central. Status post umbilical hernia repair. Otherwise, no other surgical markings noted. Positive hepatomegaly. Negative rebound tenderness. Positive tympany in all 4 quadrants. EXTREMITIES: 5/5, active and passive range of motion in all extremities bilaterally. Deep tendon reflexes are 2/4 bilaterally. Vascular: Edematous, erythematous legs bilaterally from the knees down. There is an ulcer on the upper tibia, on the right leg; +3 pitting edema, hot to touch. DP and PT pulses are 1/4 bilaterally. NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII intact. Proprioception intact. Sensory examination is intact.
PHYSICAL EXAMINATION: General: The patient is conscious, alert, and oriented. He is well built but he is malnourished with loss of muscle mass. He was not in any acute distress when I saw him. Vital signs: Temperature 99.3 degrees Fahrenheit. Heart rate is 131. Sinus tachycardia with occasional PACs and blood pressure has now improved from 91 to 118 systolic. Diastolic blood pressure is in the 70s. HEENT: Normocephalic. No jaundice. Pupils are equal and reacting to light. Neck: No jugular venous distention or lymphadenopathy. No thyromegaly. Cardiovascular system: Heart sounds are regular. S2 is single. He has flow-type systolic murmur, grade 2/6. No pericardial rub. Respiratory system: Air entry is slightly diminished over the right base, otherwise lungs are clear. Abdomen: Soft and nontender. No organomegaly or masses. Bowel sounds are slightly hypoactive. Extremities: No peripheral edema. No calf tenderness. Pedal pulses are not well palpable. No petechia or any vasculitic lesions.
PHYSICAL EXAMINATION: Examination shows an elderly female who is unresponsive to any verbal stimuli. HEENT: She has atraumatic head. Pupils are equal and sluggishly reactive bilaterally to light. Ears, externally, no infection. Oral cavity shows swollen lower lip with a cut on the lower lip, probably from biting. I am not sure how it may have happened. NECK: She has some left-sided gaze preference with some resistance to movement of the neck towards the right side. Her neck is supple anteroposteriorly. No carotid bruits could be heard. No thyromegaly. CHEST: Good bilateral air entry. No wheezes. No crackles. CARDIOVASCULAR SYSTEM: Irregularly irregular rhythm. ABDOMEN: Soft, nontender. CENTRAL NERVOUS SYSTEM: Could not be fully evaluated, but the patient does have flaccidity on the right upper and lower extremity. Left side, she has some strength. She resists to any passive movements on the left side. However, she is not following any verbal commands, but she does respond to tactile and painful stimuli. Babinski sign is equivocal bilaterally. RECTAL: Deferred. PERIPHERAL EXAMINATION: No edema, discoloration, cyanosis or clubbing.
PHYSICAL EXAMINATION: On exam at this time, blood pressure 142/52 in the right arm sitting, heart rate 72 per minute and minimally irregular and respiratory rate 18-20 per minute. Temperature was 101.2 last evening and is 98.4 at this time, weight is 286 pounds. Funduscopic exam is deferred. He has no true exanthem or xanthelasma. Jugular venous pressure is normal with no hepatojugular reflex grossly noted. No right-sided diastolic bruit is noted. No left carotid bruits are noted. There is no gross thyromegaly. Chest is clear anteriorly with scattered posterior rales in the bases bilaterally. No wheezes are present. Cardiac exam reveals normal S1, A2/P2 with no rubs, clicks, gallops, murmurs noted. Apical beat nonpalpable. Peripheral pulses are 4/4 (normal) at the radial, brachial, carotid and femoral bilaterally. Extremities show no cyanosis or edema.
PHYSICAL EXAMINATION: Currently, resting comfortably in bed. Afebrile. Vital signs are stable. HEENT: Normocephalic and atraumatic. Neck: Supple without adenopathy. Heart: Regular rate and rhythm. Abdomen: Soft, benign, and nontender. Genitourinary: Both testicles are descended. The right testicle was swollen compared to the left, is slightly tender as is the right epididymis. The inguinal canal is normal. I do not detect any hernias. Phallus is normal without lesions. Neurologic: No focal deficits.
PHYSICAL EXAMINATION: The patient is lethargic. He awakens to verbal stimulation. Neck is supple with no meningismus. Heart is regular in rhythm. Neurologically, speech is fluent. The patient answers questions. He appears oriented for the most part. He is cooperative and follows commands well. Pupils are isocoric and sluggishly reactive. Extraocular movements are conjugate. Visual fields are full to threat. Facial movements are symmetric. Tongue protrudes in the midline. Motor exam is symmetric in the four limbs at 5/5. Sensory exam is symmetric for pain perception throughout. There is no upper extremity dysmetria. Gait and stance could not be tested. Deep tendon reflexes are 1 to 2+ at the biceps and brachioradialis, 1+ at the patella, and 1+ at the ankles. Toes are mute bilaterally.
PHYSICAL EXAMINATION: On examination, the patient is alert. Neck is supple with no meningismus. Heart: Regular in rate and rhythm. Neurological: Speech is for the most part fluent. The patient is oriented to the place, unable to state the year or the month, unable to give his correct age. He does identify the current president. He is cooperative and does followup commands. His pupils are isocoric and reactive. Extraocular movements are conjugate. Visual fields are full to confrontation. Facial movements are symmetric. Tongue protrudes in the midline. Motor examination is symmetric in the four limbs at 4+/5. There is no upper extremity pronator drift. Sensory examination is symmetric for light touch and pinprick throughout. There is no upper extremity dysmetria and no gross gait ataxia. Deep tendon reflexes are hypoactive throughout, toes are mute bilaterally.
PHYSICAL EXAMINATION: Vital signs: Stable. She is afebrile. General: She is alert and oriented x3. Cranial nerves II: Visual fields are full to confrontation. Cranial nerves III, IV, and VI: Extraocular movements are intact. Cranial nerves V: Facial sensation is intact to light touch. Cranial nerves VII: No facial droop seen. Cranial nerve VIII: Auditory acuity, bilaterally symmetric finger rub. Cranial nerve IX and X: Good strong cough. Cranial nerve XII: Shoulder shrug bilaterally is symmetric. Cranial nerve XII: Tongue protrudes in the midline. Strength is 5/5 except 5-/5 in the left upper extremity. Sensation is intact to light touch. Reflexes are 2 throughout. There is no Babinski. No evidence of meningismus. There is some photophobia symptomatically.
PHYSICAL EXAMINATION: WT: He has gained some weight, he is up to 306. P: 92. BP: 125/73. RR: 22. Saturations on room air 92%. HEENT: He has no lesions or exudates. He has a stage III oropharynx. Neck is supple without adenopathy. Lungs: He has mildly decreased breath sounds but clear. Cardiac: Regular. Abdomen: Obese. Extremities: Trace edema.
PHYSICAL EXAMINATION: Vital signs stable. The patient is afebrile. She is alert and oriented to time, person, and place. Good concentration and preserved abstract thinking. There is no evidence of dementia except mild short-term memory difficulties. Her blood pressure was 126/82. She has atrial fibrillation. Heart rate is 127. Tachycardia with rapid ventricular response. She follows verbal commands. Moves all 4 extremities. No numbness. Sensory exam is normal. Reflexes are symmetric. Toes are downgoing. Gait and station are well functioning. Cranial nerves are intact. There was no carotid bruit. The patient has bilateral facial spasm and blepharospasm noticed during the exam.
PHYSICAL EXAMINATION: General: Young male, lying in bed, appears thin. Alert, awake, and oriented x3. Vital Signs: Most recent vital signs, blood pressure 99/76, pulse of 75, and respirations 19. The patient is afebrile. Head and Neck: Extraocular muscles are intact. Pupils are round and reactive. No icterus. The patient has mild pallor. No oral lesions. No throat congestion. Ears clear. Neck: Supple. No jugular venous distention. Lungs: Good bilateral air entry. Clear to auscultation. No crackles or rhonchi are appreciated. Heart: S1, S2 audible. Regular rhythm. No audible murmur. Abdomen: Soft, bulky, nontender. Positive bowel sounds. No hepatosplenomegaly appreciated. Extremities: Right hip incision appears to be clean. No evidence of pedal edema. Homans sign is negative bilaterally. Neurologic: He is grossly nonfocal.
PHYSICAL EXAMINATION: General: Elderly male who has some cushingoid features and had ecchymotic skin, lying in bed, intubated and sedated. Vital Signs: Most recent vital signs, blood pressure 119/68; pulse of 101; respirations, the patient is breathing via the ventilator. The patient is afebrile. Telemetry is showing sinus rhythm, sinus tachycardia. O2 saturation 96%. Head and Neck: Normocephalic and atraumatic. Pupils are round and reactive. The patient has ET tube in place. Neck: Supple. No jugular venous distention. Lungs: Bilateral air entry. The patient has no expiratory rhonchi. No crackles. Heart: S1, S2 audible. Regular rhythm. No audible murmur. Abdomen: Soft, bulky, nontender. Positive bowel sounds. Extremities: The patient has thin, fragile skin involving bilateral upper and lower extremities with multiple areas of ecchymosis. Does not exhibit any significant edema of lower extremities. Peripheral pulses are weak but palpable. Neurologic: He is intubated and sedated; however, he withdraws in response to tactile and painful stimuli.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.6 degrees, pulse 92, respiratory rate 19 and blood pressure 146/84. GENERAL: He is on 1 liter nasal cannula. He is in no acute distress. Neck severely flexed to the left. Soft voice with slurred speech and is very difficult to understand. LUNGS: Show decreased breath sounds in the left lower lung fields. CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs or gallops. ABDOMEN: Soft, nontender and nondistended with positive bowel sounds. EXTREMITIES: Show venous stasis dermatitis and hyperpigmentation. No edema. He has bilateral finger flexion contractions with ulnar deviation at the wrist, and as mentioned above, his C-spine, his head is flexed to his left shoulder. He can actively reduce approximately half of his flexion. NEUROLOGIC: Unable to obtain a mental status exam, although he appears to be comprehending our questions and nodding appropriately. His cranial nerves are grossly intact. Pupils are equal, round and reactive to light. His strength is 4+ to 5 throughout. Sensation: He reports good light touch sensation throughout, although testing is limited. His muscle stretch reflexes are 2+ in the right upper extremity, 1 in the left upper extremity, 3+ at the right knee, 0 at the left knee, 2+ at the right ankle, 0 at the left ankle with downgoing toes bilaterally. No Hoffmann. No palmomental. No grasp reflex.
PHYSICAL EXAMINATION: VITAL SIGNS: Vitals are pending. GENERAL: The patient is a (XX)-year-old male, pleasant, alert and cooperative, follows all commands appropriately, sitting in a wheelchair, speaking with mild dysarthria, in no distress. HEENT: Extraocular muscles are intact. HEART: Regular rate and rhythm with a 2/6 systolic murmur. LUNGS: Clear to auscultation bilaterally. EXTREMITIES: Right hand and right ankle and lower leg edema. NEUROLOGICAL: Cranial nerves III through XII are grossly intact, except for cranial nerve XI. Right shoulder shrug is impaired. Cranial nerve XII, tongue deviates to right. There is also a right facial droop. Strength: Left upper and lower extremity 5/5. Right upper extremity: Elbow flexion 2-/5 with no other voluntary movement in the upper extremity. Hand is flaccid. Right lower extremity: Hip flexion 3-/5 and knee extension 3+/5. Right ankle dorsiflexion 1/5. Sensation intact to light touch and to 10 g monofilament bilaterally. Stereognosis intact on the left, unable to test on the right secondary to flaccidity. Graphesthesia intact on the left and mildly impaired on the right. It took the patient several repetitions in order to name the appropriate number drawn in the palm of his hand. Cerebellar finger-to-nose-to-finger is intact on the left. Rapid alternating movements with index finger tapping to thumb were intact on the left. No ataxia. The patient was unable to perform with the right upper extremity. Mental status: The patient had difficulty counting coins in the hand when a quarter, dime, and penny were placed in view.
PHYSICAL EXAMINATION: The patient was seen sitting up in a chair with both wrists restrained on the wheelchair, well-healed craniotomy scar with tracheostomy in place, with significant secretions with moist air mask over the tracheostomy. The patient uttered unintelligible words. With his tracheostomy plugged, he still was unintelligible. He was intermittently fluent but really no language examination could be done because of his significant confusion. His mental status examination was severe confusion with lethargy, alternating with some short-lived motor restlessness in which he picked the tubes or would pull and hold on to his tracheostomy mask line. He never really pulled his tracheostomy tube or any of his IVs. He has not pulled his PEG or his Foley catheter. His cranial nerve examination is remarkable for poorly visualized fundi. The patient was moving and restless, and at other times, too lethargic to cooperate. Blinks to threat, both eyes. Pupils are equal and reactive. I did not see any evidence of third nerve palsy, and the patient has no asymmetry of his face that I could judge. He was uncooperative with oral evaluation of the pharynx. Tongue appeared midline in the mouth. No carotid bruits but auscultation obscured by tracheostomy sounds, tracheostomy in place. Motor examination shows the patient to be equally resistant to any sort of passive movement in both arms, in a gegenhalten or paratonic rigidity style. There was some decreased withdrawal to pain on the right side suggestive of a mild underlying right hemiparesis. Reflexes were absent in the ankles, 1 at the knees, 1 in the arms, and he has a positive palmomental. Toes are nonreactive. Limb ataxia could not be judged and gait was not attempted.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.5 degrees, pulse 86, respirations 18 and blood pressure 154/82. GENERAL: The patient is a (XX)-year-old white female, pleasant, alert and cooperative, lying semi-reclined in bed, in no acute distress. She does have pressured speech, and there is a mild left facial droop. HEENT: Extraocular muscles are intact. No nystagmus. Moist mucous membranes. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally without murmurs. ABDOMEN: Positive bowel sounds, soft, nontender and nondistended. EXTREMITIES: No peripheral edema. NEUROLOGIC: Strength: Right upper and lower extremity, 5/5. Left shoulder abduction, 3+/5; left elbow flexion, 4/5; and left grip, 4/5. Left knee extension, 4+/5; left ankle dorsiflexion, 4+/5; and left toe extension, 4+/5. Sensation intact to light touch, bilateral, upper and lower extremities. Deep tendon reflexes; 3+/4 bilateral biceps, brachioradialis and patellar. Babinski is present on the left. Mental status: The patient is oriented x3. She speaks with a pressured-type speech. There is a no dysarthria. Cranial nerves II through XII are grossly intact, except for decreased strength in left cranial nerve XI, decreased shoulder shrug.
PHYSICAL EXAMINATION: GENERAL: The patient is a well-nourished, well-developed female, in no apparent distress. VITAL SIGNS: Temperature 97.5 degrees, blood pressure 129/67, pulse 83 and respiratory rate 18. SKIN: Warm and dry with good color and turgor. There were a few ecchymotic areas present consistent with phlebotomy site. She does have a G-tube in place. No rash is present at the present time. No skin breakdown. HEENT: She does have mild right facial droop. She is otherwise normocephalic and atraumatic. PERRLA. EOMI. There is no gross afferent pupillary defect or conjugate gaze. TMs were clear. Oral mucosa was moist and pink. She is edentulous. NECK: Soft and supple without lymphadenopathy, JVD or bruit. HEART: Regular rate and rhythm without murmurs, rubs or gallops. LUNGS: Clear to the bases bilaterally. No rhonchi, rales or wheezes. ABDOMEN: Obese but soft, nontender and nondistended. Bowel sounds were active. No rebound, guarding, pulsating masses or bruits. No CVA or suprapubic tenderness. BACK: Back, spine and paraspinal areas were unremarkable with equal wall motion and symmetrical musculature. GENITOURINARY: Normal-appearing female. She has a mild erythematous area with breakdown, sacral or right buttock area. Tegasorb dressing is in place, approximately 1-2 cm in diameter. EXTREMITIES: There is no clubbing or cyanosis. Trace of edema bilaterally, 2+ dorsalis pedis, posterior tibial and radial pulses. Reflexes: The patient is hyperreflexive on the left side, appears to be normoreflexive on the right. Toes were downgoing on the right, up in the left. Negative Babinski. Unable to perform heel-to-shin secondary to left side neglect. Finger-to-nose also likewise.
OBJECTIVE: Temperature 98.4 degrees, pulse 80, respirations 30 with a recheck of 22, and blood pressure 112/82. The head and neck examination was unremarkable, except for some male pattern baldness, and the patient is receiving 2 liters of oxygen via nasal cannula. There is no pursed lips breathing. There is no accessory muscle use for respiration. The lungs were clear to auscultation, except for some decreased breath sounds in the bases. The heart had a regular rate and rhythm without murmur. The abdomen was soft, nontender, with active bowel sounds. A paradoxical pattern of breathing was noted. Thigh-high Ace wraps and TED hose were worn. A thigh strap was in place to aid with leg positioning. There is a PICC line in the left arm. Trace lower extremity edema was noted.
OBJECTIVE: Temperature 97.4 degrees, pulse 91, respirations 17, and blood pressure 127/81. The head and neck examination showed a healing scar on the left lip. She was wearing a TLSO with Minerva extension. The brace was fitting well. Heart and lung examinations were within normal limits. The abdomen was soft, nontender, with active bowel sounds. There was no lower extremity edema. Modified Ashworth score was 2-3.
PHYSICAL EXAMINATION: Temperature 97.2 degrees, respirations 19, pulse 93, and blood pressure 132/64. He is alert, he is oriented, but sustained attention is quite poor. Simple attention is intact. He is concrete in his abstractions. Short-term recall is very poor for information about his hospitalization. Prior levels of function are declined, even his prior graduation history from college. His language is a little bit dysarthric. Insight into his condition is moderately impaired. He is concrete on abstractions and similarities. Cranial nerves: He has a history apparently of alternating exotropia. It looks like that is what it is rather than internuclear ophthalmoplegia, but he does have a left APD. Disk is pale on the outside. The pupils are reactive and the left pupil is slightly larger than the right. He has flattening of the right face but intact sensation, spastic gag, and intact sensation in the palate and midline tongue. Carotid examination is unremarkable. Cardiac examination reveals regular rate and rhythm. No murmur. Motor: The patient has good strength in his upper extremities, bilateral thigh. Reflexes are 1 in the arms. In the legs, he has clonus at the ankles, but I could not get reflexes. Lower extremity strength is 3- in the left iliopsoas, 2 on the right, 3- in the quads bilaterally, 2 in the hamstrings and 2 to 3- in the dorsiflexors. He has decreased proprioception in both hands and both feet. Vibration is diminished to the knees. He has moderate ataxia on finger-to-nose. Legs are not tested due to weakness. Gait was not attempted but he has moderate impairment in trunk control, though he does have some trunk control and sits reasonably well on the scooter chair. He has significant truncal ataxia.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 143/82, pulse 86, respirations 21 and unlabored. GENERAL: She is a large, well-nourished, white female, in no acute distress. Has numerous superficial lacerations and abrasions. SKIN: Has fair color and turgor. Difficult to ascertain much secondary to numerous dressings, including wound VAC. HEENT: She appears grossly atraumatic. There is no gross asymmetry. She has numerous avulsed teeth. She appears to have no malocclusion. The mandible is nontender. She had normal midline structures. PERRLA. EOMI. No APD. There is conjugate gaze. She does not have raccoon eyes. Cannot appreciate any gross step-off. TMs were clear bilaterally. No gross bleed. Nose is nontender on evaluation presently. NECK: Soft and supple without JVD or bruit. She does have mild submandibular lymphadenopathy present. It is nontender however. It is bilateral and symmetrical. She has fair range of motion. She does have a soft collar brace on at this point of time. It is more for comfort of the patient at this point in time. BACK: Back and spine and paraspine were unremarkable with equal chest wall motion. HEART: Regular rate and rhythm with 1/6 systolic ejection murmur. CHEST: Had slightly diminished breath sounds bilaterally at the bases. No gross rhonchi, rales or wheezes. Normal PMI. ABDOMEN: She has a large abdominal wound with wound VAC in place. Black sponge dressing in place. It is set to 125 mmHg. No present drainage at this time. She has bilateral casts on upper extremities as well as one on lower extremities, short leg walking cast. There appears to be some yellowish drainage present as well as some slough material about the periphery of the abdominal wound itself and has appropriate tenderness and mild erythema about the edges present, 1-2 cm; however, there is no gross induration appreciated. She has numerous casts, superficial lacerations, abrasions and contusions. Hemovac to the left hip area for revision of left hip ORIF, that was discontinued prior to discharge. GENITOURINARY: Normal-appearing female. EXTREMITIES: As stated above. Proprioception is preserved; however, difficult to ascertain secondary to pain in the left lower extremity. Capillary refill and nail beds appear to be pink and appropriate. Motor is intact in all extremities. NEUROLOGIC: Neurologically, I cannot appreciate any gross deficits at this time. However, this is difficult secondary to numerous casts and obstructions on evaluation. She appears to have a small, possibly, pressure sore on the left heel, slightly violaceous in color. There is no skin breakdown. It is no fluctuant. It is not soft or mushy. Cannot appreciate gross heel-to-toe at this point in time secondary to casting. The patient is not able to ambulate around at this point in time, as she likely is nonweightbearing on the left lower extremity. Cranial nerves do, however, appear preserved bilaterally.
PHYSICAL EXAMINATION: Temperature 98.5 degrees, pulse 101, respirations 18, blood pressure 141/78 and oxygen saturation 97%. Eyes are open with a left gaze deviation, right hemiplegia, which is flaccid, right decreased blink to threat. I could not examine her oropharynx, as she was unable to open it. Pupils were equal and reactive, and fundi were poorly visualized. Reflexes were absent throughout. She does move the left arm spontaneously but not the left leg. She withdraws the left leg to pain, and she grimaces to pain for all four extremities. She has foot drop bilaterally, worse on the right, and her toes are unreactive.
PHYSICAL EXAMINATION: General: The patient was comfortable at the time of examination and no shortness of breath. Vital Signs: Blood pressure 126/77, pulse 88, afebrile, with respiratory rate of 18 per minute. Head and neck examination: Pink conjunctivae, anicteric sclerae. Normal eye movements. Mouth, no lesions. Neck: Supple. No jugular venous distention, tenderness, thyromegaly, lymphadenopathy or masses. Chest: Bilateral equal expansion, resonant to percussion, with clear air entry bilaterally. Heart: Normal S1 and S2. No S3. No murmurs or gallops. Abdomen: Benign, nontender and nondistended. No masses, organomegaly or ascites. Limbs: No finger clubbing or pedal edema. Neurologic examination: The patient is alert and oriented x3. No signs of focal motor, sensory or neurological deficits. Skin: Normal. Lymph nodes: None detected.
PHYSICAL EXAMINATION: Shows a well-developed, well-nourished white female, conscious, alert, oriented, in slight distress due to pain in the left hip. The patient is afebrile. Vital signs are stable. HEENT: Normocephalic. Eyes: Pupils equal, round, reactive to light and accommodation. Extraocular movements are full and equal. Neck shows no palpable tenderness or spasm. No lymphadenopathy or thyromegaly. Fair range of motion. At the present time, the patient is lying supine with pillow between her legs, and on removal of the pillow, the patient still has a flexion contracture in the left hip. There is a large ecchymosis, approximately 9 x 10 cm over the left greater trochanter area, and clinically, there are no fluctuations suggesting hematoma. Diffuse tenderness in the groin and over the lateral hip area. Range of motion of the left hip is reduced in all planes with spasm around the hip. There is no rotational deformity of the left lower extremity but possibly minimal shortening compared to the right lower extremity. CNS: Sensation intact in all dermatomes. Deep tendon reflexes 1+ and equal. Plantar reflexes bilaterally. Pedal pulses are faint but present both sides.
PHYSICAL EXAM: VITAL SIGNS: Temperature is 97.5 degrees, pulse 72, respirations 19, and blood pressure 142/64. HEENT: Head is atraumatic, normocephalic and without bony deformities. Ears are unremarkable for bulging, retraction of TMs, erythema, drainage or PE tubes. Eyes: Pupils are equal, round and reactive to light and accommodation. EOMS intact. No evidence of ptosis or conjunctivitis. Nose: Nasal mucosa is pink and dry without evidence of erythema, drainage, or lesions. Throat: The patient’s oral cavity is unremarkable for exudate, erythema or oral candidiasis. NECK: Supple without JVD, goiter or lymphadenopathy. LUNGS: Clear to auscultation. No rhonchi, wheezing or rales heard. HEART: Tachycardic with a heart rate of 103. No murmurs, rubs or gallops heard. ABDOMEN: Soft, obese and nontender. Bowel sounds are present in all four quadrants. EXTREMITIES: The patient’s right knee incision site is clean, dry and intact. There is mild erythema, warmth and edema present around the right knee. The wound appears dehisced and shows no evidence of purulent drainage or odor. No calf tenderness on exam. The patient does have palpable DP pulses bilaterally. NEUROLOGICAL: The patient is alert and oriented to person, place and time. Cranial nerves II through XII appear intact. No evidence of sensory loss. Upper extremity motor strength is 5/5. Left lower extremity motor strength 5/5. Right hip flexion 0/5. Right knee flexion 3/6. Right EHL 5/5. SKIN: Unremarkable for pressure wounds.
PHYSICAL EXAMINATION: Shows a well-developed, well-nourished white female, conscious, alert, oriented, in no acute distress. The patient is afebrile. Vital signs are stable. HEENT: Normocephalic. Eyes: Pupils equal, round, reactive to light and accommodation. Extraocular movements are full and equal. Neck shows no tenderness or spasm. No lymphadenopathy or thyromegaly. Extension is slightly limited with no pain. There is a left below-knee amputation stump. Tip is conical with no tenderness, good range of motion of the knee. Right lower extremity is noted to be slightly swollen and indurated and with slight erythema. The skin is dry and scaly. There is a 2.6 x 2.2 cm ulcer of the lateral aspect of the right heel with very minimal slough in the base. No active drainage is seen. Slight erythema around the ulcer edges, which does not appear to extend too deeply. Minimal tenderness around the ulcer margins. Pedal pulses not palpable. Toenails are noted to be thickened and brittle with possible fungal infection. Sensation is reduced in the foot. Fair range of motion of the ankle and toes.
PHYSICAL EXAMINATION: General: The patient is an elderly gentleman appearing his stated age and who is hemodynamically stable. HEENT: Normocephalic and atraumatic. Pupils equal, round and reactive to light and accommodation. Extraocular movements intact. Mouth is without lesions. Neck: Supple without thyromegaly. No jugular venous distention or bruits noted. No lymphadenopathy noted. Chest: Clear to percussion and auscultation. Cor: S1 and S2. No S3 or S4 noted. Positive 2/6 murmur heard over the precordium. Abdomen: Scaphoid, soft and benign. Bowel sounds are normoactive. There is no hepatosplenomegaly noted. Extremities: Reveal bilateral 3+ pitting edema with erysipelas extending three-fourths on the left and two-thirds on the right. Neurologic: The patient is alert and oriented x3. Cranial nerves II through XII are intact. Motor and sensory systems are normal.
PHYSICAL EXAMINATION: General: The patient is a well-developed, well-nourished white male who appears to be in no acute distress. Vital Signs: Blood pressure is 152/74 and weight is 178. HEENT: Within normal limits. There is no scleral icterus. Lungs: Clear to A and P. Heart: Soft, 1 to 2/6 systolic murmur. There is no gallop or rub. Abdomen: Scars from previous surgery. There is no organomegaly or masses. Bowel sounds are present. There is no tenderness. Rectal: Heme-negative stool. There are no masses. Extremities: No clubbing, cyanosis or edema. Neurologic: Grossly intact.
PHYSICAL EXAMINATION: General: The patient is an averagely built, elderly white male, who is not in acute distress. Vital Signs: Stable, as noted on the chart. HEENT: Examination unremarkable. Neck: Supple. No carotid bruits. Heart: S1 and S2 are normal. No murmur, gallop or rub. Lungs: Clear. Neurologic: He is alert. He knows he is in the hospital. He has no recollection of events from yesterday, clearly. He follows commands appropriately. His speech is dysarthric, which is unchanged from his previous exams. Pupils are 3 mm, round, reactive to light and accommodation. No visual field defects. Extraocular movements are full and no nystagmus. Mild left facial weakness, of central type, is still seen, residual from previous stroke. Other cranial nerves intact. He appears to be swallowing fairly well. Motor examination reveals spastic left hemiparesis. Strength is 0/5 in the left upper extremity and 3 to 4/5 left lower extremity, which is unchanged from previous one, 5/5 on the right side. Generalized hyporeflexia. Plantar response is downgoing on the right, upgoing on the left.
PHYSICAL EXAMINATION: General: The patient is an overweight, middle-aged white female not in acute distress. Vital Signs: Stable as noted on the chart. HEENT: Examination unremarkable. Neck: Supple. No signs of meningeal irritation. No carotid bruit. Heart: S1 and S2 normal. No murmur, gallop or rub. Lungs: Clear. Neurologic: She is alert and oriented in all three spheres, generally pleasant and cooperative. No dysarthria or aphasia. Memory grossly intact. Pupils are 4 mm, round and reactive to light and accommodation. No visual field defects. Extraocular movements are full. No nystagmus. No facial asymmetry. Auditory canals are intact. Muscle bulk and tone are within normal limits. No evidence of any focal, motor or sensory deficits. She does have some limitation of the right knee movement because of pain. Intact deep tendon reflexes, which appeared to be hypoactive. Plantar response is downgoing bilaterally. Finger-to-nose test did not show any ataxia.
PHYSICAL EXAM: Vital Signs: Blood pressure 133/85, heart rate 80, respiratory rate 19 and temperature 97.5 degrees. Weight 208 pounds. Height approximately 5 feet 7 inches. HEENT: Head is normocephalic. Conjunctivae are pink. Oropharynx is clear. Neck: Supple. There are no masses. There is no tenderness. Chest: Without any deformities. Abdomen: Soft and nontender without organomegaly. Extremities: Did not show any cyanosis or clubbing. Neurologic: Mental status, he is alert and he is cooperative. Speech is dysarthric. He has difficulty with his saliva and was coughing because of this. Tongue is midline. He has good shoulder shrugs. Motor examination showed he had 5/5 strength in the upper and lower extremities. No gross ataxia was noted on finger-to-nose testing. Gait is not tested. There was no facial numbness.
PHYSICAL EXAMINATION: Temperature 98.2, pulse 82, blood pressure 118/70 and T-max 100. In general, the patient is awake and alert. He is sitting in a chair. He is able to answer some questions but does appear to have some trouble with memory. HEENT: Pupils are reactive bilaterally. Sclerae anicteric. Conjunctivae noninjected. Oral mucosa moist. No thrush or pharyngitis. Neck: Supple. Trachea midline. No palpable thyromegaly. Lymph: No frank cervical, supraclavicular or epitrochlear adenopathy. Chest: Symmetrical excursion. Lungs are clear to auscultation without wheezes. The port site is in the right pectoral area and does not appear to have any redness or tenderness. Cardiac: Regular rate and rhythm without rub. Abdomen: Nondistended. Normoactive bowel sounds. No guarding or rebound tenderness. Ileal conduit is present in the right lower quadrant. The ostomy site appears to be pink. Urine appears fairly clear with only a small amount of sediment noted. Back: No CVA tenderness. Extremities: No clubbing or cyanosis. No palpable cords. No calf tenderness to palpation. The patient appears to have good peripheral muscle tone to palpation. The skin is without diffuse rash. No vesicles or bullae. No Janeway lesions or Osler nodes. Peripheral IV site has no cellulitis or phlebitis.
PHYSICAL EXAMINATION: The patient denies mental status examination. The patient is an average built, casually groomed male with swollen left eye and in no acute distress. He was pleasant and cooperative and maintaining good eye contact. There was no evidence of any psychomotor dysfunction. His affect was euthymic and he described his mood as “good.” His speech was clear, coherent and goal directed and there was no evidence of any formal thought disorder. The patient reported vague paranoid ideation during the time of cocaine intoxification, but currently denies any overt psychotic symptoms or any previous history of psychosis or other significant difficulties besides violent behavior and antisocial behavior. Cognition: The patient was alert and oriented to person, place and time. His recent and remote memories were fair. His attention and concentration were fair. His fund of knowledge appears to be below average and his insight and judgment were poor.
PHYSICAL EXAM: This is an elderly male, confused and disoriented, but in no apparent distress. Blood pressure is 110/53, heart rate of 113, respiratory rate of 24 and saturation with 2 L nasal cannula is 100%. HEENT: Unremarkable. Neck: Jugular venous pressure is within normal limits. Carotid upstrokes are normal. No carotid bruits. Lungs: Clear to auscultation. Heart: PMI nondisplaced. The first and second heart sounds are normal in intensity. There is a 1/6 systolic murmur, heard best below the apex. Abdomen: Soft and nontender with active bowel sounds. No organomegaly. No abdominal bruits. Extremities: No clubbing or cyanosis. There is trace edema in the feet. Neurologic: Grossly nonfocal. Peripheral pulses are 2+/2, equal bilaterally.
PHYSICAL EXAMINATION: The patient is a (XX)-year-old woman who is alert and oriented x3, comfortable at rest. Her vital data includes a temperature of 98.5, heart rate 72, blood pressure 142/82 and respirations 21. Head and neck examination shows pupils equal, round, reacting to light and accommodation. Extraocular muscles are intact. ENT examination is normal. There is no JVD. There is no lymphadenopathy. No thyromegaly. Neck is supple. Chest examination shows first and second heart sounds, normally heard. No third sound, no fourth sound, and no murmurs. Auscultation of the lungs shows bilateral vesicular breath sounds. Examination of the abdomen shows a soft and scaphoid abdomen. There is a longitudinal scar in the midline, which is a healthy scar. There is a deep tenderness in the epigastrium in the left upper quadrant of the abdomen. There is no rebound tenderness. No hepatosplenomegaly. No ascites. Normal peristaltic sounds are heard. Extremity examination shows no edema. No rash. No focal neurological deficit.
PHYSICAL EXAM: Reveals alert and cooperative gentleman whose weight is 160 pounds, temperature 99.5, pulse 92, respirations 18, blood pressure 131/74 and O2 saturation is 96% on room air. HEENT: Shows him to be normocephalic. There is no gross scleral icterus, conjunctival petechiae or pallor. Mouth and Throat: Clear. Neck: Supple and nontender. No palpable mass or adenopathy. He has a well-healed thyroidectomy incision. Chest: Shows some percussion and auscultation and did not show any focal wheezes or rales. On the defibrillator side, left upper chest has some hemorrhagic brawny changes. It does not appear to show any fluctuance, significant pain or spreading cellulitis. A well-healed old sternotomy incision. Heart: Reveals normal S1 and S2. No significant rub or gallop. No significant pedal edema. Abdomen: Soft. Percussion is normal. Palpation does not elicit any hepatosplenomegaly, rebound, guarding, or tenderness. There is no flank or CVA pain. External genitalia, normal male. The patient does not have any inguinal adenopathy or tenderness. Musculoskeletal: Shows no gross deformities or abnormalities. No spine pain or CVA tenderness on percussion. Neurologic: Deep tendon reflexes are symmetric. The patient is alert and oriented, does not exhibit any gross cranial nerve deficits.
VITAL SIGNS: Temperature 98.6, pulse 64, blood pressure 126/78, pulse oximetry 98% on room air.
GENERAL: The patient is a pleasant female, in no acute distress.
HEENT: Normocephalic and atraumatic. Extraocular movements are intact. Pupils are equal, round, reactive to light and accommodation. Sclerae without icterus. Oral mucosa is smooth and pink without ulceration or exudate.
LYMPH NODES: No cervical, supraclavicular or axillary adenopathy on either side.
LUNGS: Clear to auscultation and percussion without wheezes, rhonchi or rales.
CARDIOVASCULAR: Regular rate and rhythm without murmurs, gallops or rubs.
BREASTS: Examination of the left breast reveals a biopsy site in the upper outer quadrant. Beneath this biopsy site is about 3.5 x 3.5 cm of induration consistent with a palpable hematoma. No other abnormalities noted on left breast examination. The right breast is soft and normal to palpation. No skin or nipple changes. No nipple discharge.
LUNGS: Clear to auscultation and percussion without wheezes, rhonchi or rales bilaterally.
ABDOMEN: Soft and nontender. Bowel sounds are present in all 4 quadrants. No rebound tenderness. No guarding. No hepatosplenomegaly.
EXTREMITIES: Without upper or lower extremity edema. No calf tenderness. No cyanosis, no clubbing.
SKIN: No abnormal nevi, ecchymosis, petechiae or rashes.
PSYCHIATRIC: Normal mood and affect. Normal judgment.
VITAL SIGNS: Blood pressure 86/52, heart rate 132 and irregular, temperature in the emergency department on admission 100.8.
HEENT: The head is atraumatic. Pupils are equal and reactive. Dentition is intact without abscesses. Oral mucosa is normal without masses.
NECK: No lymphadenopathy, JVD or carotid bruits.
CHEST: Unremarkable with symmetric chest movement. There are no obvious masses or deformities. Right subclavian line in place.
CARDIOVASCULAR: The PMI is not displaced. There is no palpable thrill. Heart rate is normal with S1, S2, without S3 or S4 appreciated. There is no obvious gallop or rub.
VASCULAR: There are 2+ carotid pulses, femoral pulses, radial pulses and pedal pulses.
ABDOMEN: The abdomen is soft and nondistended with normoactive bowel sounds. There is no evidence of hepatosplenomegaly. It is nontender without guarding and there are no masses.
EXTREMITIES: No clubbing, cyanosis or edema.
MUSCULOSKELETAL: Gait is normal with normal alignment of the vertebral column and good muscle tone of both upper and lower extremities.
BACK: There is no CVA tenderness.
SKIN: No obvious rashes or lesions. There is a large decubitus about 3.5 cm in greatest diameter that appears to have necrotic margins. There is a purulent-looking exudate at the base of the wound.
PSYCHIATRIC: The patient is oriented and conversant. Mood and affect are appropriate.
NEUROLOGIC: No gross motor or sensory abnormalities noted.
VITAL SIGNS: Blood pressure 194/100, heart rate 98, oxygen saturation 99% on 2 liters.
GENERAL: The patient is lying on the bed, in no acute distress, appears slightly anxious.
HEENT: The patient has mild left facial droop. Visual fields are intact. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are full and conjugate.
HEART: The patient has systolic murmur. Regular rate and rhythm.
LUNGS: No coarse lung sounds and wheezes, otherwise diminished throughout.
ABDOMEN: Soft, nontender and nondistended.
EXTREMITIES: The patient has bilateral lower extremity edema.
NEUROMUSCULAR: The patient is awake, alert and oriented x3. Speech is moderately dysarthric. The patient follows simple commands. Cranial Nerves: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are full and conjugate. Visual fields are intact. The patient has a left facial droop. Tongue and uvula are midline. Positive corneal reflex. Motor: The patient moves the right upper extremity. Full strength is 5/5. Right lower extremity is generally weak. The affected side is the left side. Left upper extremity strength is 3/5 and left lower extremity is 1/5. Sensation is decreased on the left. Coordination: No limb ataxia noted.
VITAL SIGNS: Blood pressure 156/80, pulse 112 per minute, respiratory rate 21 per minute, temperature 98.6 and oxygen saturation 94% on room air.
GENERAL: This is a well-nourished, nontoxic-looking female who is able to speak in full sentences.
HEENT: Head is normocephalic and atraumatic. There is equal ocular movement bilaterally. External ears and nose appear normal. The oropharyngeal mucosa is moist.
NECK: Supple without thyromegaly, cervical adenopathy or jugular venous distention.
CHEST: Bibasilar crepitations with diminished air entry, no wheeze heard.
HEART: Normal first and second heart sounds are heard, regular in rate and rhythm, without any murmurs, rubs or gallops.
ABDOMEN: Soft, nontender and nondistended. Bowel sounds are present. There is no palpable hepatosplenomegaly.
CENTRAL NERVOUS SYSTEM: The patient is alert and oriented x3 without any focal neurological deficits.
EXTREMITIES: Peripheral pulses are palpable but there is no peripheral edema. There is no calf tenderness or evidence of tenosynovitis.
SKIN: Warm and dry without any active rash or lesions.
GENERAL: The patient is a chronically ill-appearing man, who looks stable at this point.
VITAL SIGNS: Initial blood pressure was 86/56, heart rate 72, respiratory 21, temperature 98.4 and saturations of 98% on room air. Blood pressure now appears to have improved to 98/64.
HEENT: Head is normocephalic and atraumatic. Pupils are round and reactive to light. No conjunctival pallor or icterus. Buccal mucosa was slightly dry. Pharynx had no redness or swelling.
NECK: Supple. There was no jugular venous distention or thyromegaly. No carotid bruits. No palpable lymphadenopathy.
CHEST: Reduced air entry at the lung bases. Did not hear any wheezing but did have harsh breath sounds bilaterally with slightly prolonged expiratory phase of breathing.
HEART: Pulse is symmetric and regular. Heart sounds 1 and 2 were heard. No murmurs, gallops or rubs.
ABDOMEN: Distended. Had positive fluid thrill. Did have vague tenderness diffusely. Bowel sounds normal.
EXTREMITIES: The patient had no cyanosis or clubbing. He had bipedal edema, pitting, bilaterally.
CENTRAL NERVOUS SYSTEM: The patient was alert and oriented in 3 spheres. Cranial nerves II-XII are essentially intact. Power was grade 5/5 globally.
VITAL SIGNS: Blood pressure 96/54, pulse 56, respirations 21, temperature 98.2 and O2 saturations 97% on room air.
HEENT: Head is normocephalic and atraumatic. Pupils are equal and round. Nares clear. Oropharynx clear without lesion or exudate.
NECK: Supple without lymphadenopathy or jugular venous distention.
LUNGS: Clear to auscultation. No wheezes, rales or rhonchi. Respirations are even and unlabored. No use of accessory muscles.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
NEUROLOGIC: The patient is alert and oriented x3. Speech is fluent. The patient follows commands. Attention is intact. Has intact long-term and short-term memory. The patient is able to register and remember 3/3 words. Cranial Nerves: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are full and conjugate. Face is symmetric. Facial sensation is intact. Tongue and uvula are midline. Motor: The patient moves all extremities with full strength of 5/5. No abnormal fasciculations or tremors. Sensation is intact to light touch and cold stimulus. Coordination: No limb ataxia with finger-to-nose or heel-to-shin testing. Deep tendon reflexes are normal throughout. The patient has bilateral downgoing toes with plantar reflex. Gait: The patient’s gait is normal and steady without assistance.
VITAL SIGNS: Temperature 97.8, axillary; pulse 101; blood pressure 96/44; respiratory rate 32.
GENERAL: This is a small-for-age female with obvious delays.
HEENT: Head is normocephalic and atraumatic. Conjunctivae clear. Pupils are equal, round and reactive to light bilaterally. Tympanic membranes are clear bilaterally with tympanostomy tubes in place. Midline is somewhat flattened with well-healed cleft palate repair. Incision site noted. Moist mucous membranes. Positive drool present. Oropharynx is clear with moist mucous membranes. No erythema noted. Nares clear.
NECK: Supple with no lymphadenopathy. No nuchal rigidity.
LUNGS: Clear to auscultation bilaterally with no wheezes, rales or rhonchi. No accessory muscle use noted.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops. Pulses are 2+ and equal bilaterally. Brisk capillary refill. Port site is clean, dry and intact.
ABDOMEN: Soft and nondistended with no hepatosplenomegaly. G-tube site is clean, dry and intact.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No rashes or lesions.
NEUROLOGIC: At baseline, the patient is quite active, smiling, moving around the bed. No focal deficits noted.
GENERAL: A morbidly obese (XX)-year-old female, sitting in exam chair, walks into the exam room with a cane, in no obvious distress.
VITAL SIGNS: Pulse 72, respirations 18, blood pressure 122/80. Height 5 feet 6 inches. Weight 250 pounds.
HEENT: Pupils are equal, round and reactive to light and accommodation. Sclerae anicteric. Oral cavity moist, pink with 1 to 2+ tonsillar hypertrophy and small crypts. No exudate, erythema or obstruction.
NECK: Supple. No JVD, adenopathy or thyromegaly.
LUNGS: Decreased breath sounds but essentially clear.
HEART: RRR. No S3, S4, murmur or carotid bruits.
ABDOMEN: Centrally obese, soft, positive bowel sounds. Healed laparoscopic incisions and midline vertical incision from the umbilicus to the suprapubic area consistent with surgical history. Organomegaly not appreciated. No tenderness, masses or rebound.
RECTAL: Exam deferred.
PERIPHERAL VASCULAR: Extremities warm and dry without edema.
MUSCULOSKELETAL: Near full ROM of all the major joints.
NEUROLOGIC: Motor strength 4/5 of all the major muscles. Sensation intact to all the major dermatomes, except decreased to light touch from the toes up to the lower to mid shins bilaterally and circumferentially. Gait with somewhat widened base support, slightly unsteady, but uses a cane for gait stability without gross ataxia.
OBJECTIVE: On examination of the left lower extremity, the skin is circumferentially intact. There is no knee effusion. The foot is warm and well perfused with brisk capillary refill. Sensation is intact to light touch distally, in the distribution of the sural, saphenous, superficial, peroneal, deep peroneal and tibial nerves. She is able to perform straight leg raise against gravity. She is able to actively dorsiflex and plantarflex the foot and toes against gravity. The extensor mechanism is intact. Passive range of motion is from full extension to 145 degrees of knee flexion; the arc of motion is pain-free. There is no medial or lateral joint line tenderness to palpation. The knee is stable to varus and valgus stress testing at 0 and 30 degrees of knee flexion. The Lachman test demonstrates firm endpoint. The posterior drawer test demonstrates firm endpoint. There is no calf pain, swelling or tenderness to palpation. The skin is intact over the heel. There is mild quadriceps muscle atrophy. There is no tenderness to palpation over the proximal tibia. Her gait is examined; it is nonantalgic in nature. She has no instability today, clinically, when she is bearing weight.
PHYSICAL EXAM: On examination today, the patient appears well nourished and well developed. She is pleasant and cooperative. Weight is 164 pounds. Blood pressure is 118/64. Pulse is 74. Respirations are 16. Pain level is 0/10. Neck is supple. Head is normocephalic and atraumatic. Neurological examination is normal. The patient is awake, alert, pleasant and cooperative. Speech demonstrates normal initiation and articulation with no paraphasic errors. Memory is intact. Cranial nerves II-XII are normal. Could not visualize the fundi easily. Motor exam demonstrates normal bulk, tone and strength in all 4 limbs. Reflexes are symmetrically intact in all 4 limbs. Toes are flexor. There are no extrapyramidal signs or adventitious movements. Gait is normal. Sensation is intact for primary modalities throughout. The patient has no neck or cranial trigger points. There is no temporal artery enlargement. There is no temporomandibular joint crepitus.
VITAL SIGNS: Blood pressure 128/74, pulse 84, temperature 97.6, oxygen saturation 96% on room air. Weight 182 pounds.
GENERAL: The patient is alert, oriented, pleasant, in no acute physical distress. Does not seem anxious or depressed. Appropriate and cooperative with exam.
HEENT: Pupils are equal, round and reactive. EOMs are intact. Oropharynx is benign.
NECK: Supple. No lymphadenopathy or thyromegaly. C-spine range of motion is intact.
CHEST: Lung sounds are clear to auscultation with a normal respiratory effort.
CARDIOVASCULAR: Regular rate and rhythm. S1, S2. No S3, S4 or murmur.
ABDOMEN: Soft, flat, nontender, nondistended. Normal bowel sounds. No guarding, rebound, masses or rigidity.
BREASTS: No axillary lymphadenopathy, skin retraction or nipple discharge. No masses palpated.
GYNECOLOGIC: External genitalia: Tanner stage V, normal, without lesion. Vagina is pink with minimal rugae. Cervix visualized midline. Pap is obtained. Bimanual: Negative for CMT, adnexal tenderness or masses.
NEUROLOGIC: No focal deficits. DTRs are intact.
MUSCULOSKELETAL: Normal bulk and tone. Ambulates with a rolling walker and transfers to exam table with one assist.
INTEGUMENT: Warm and dry without rash or suspicious lesions.
PHYSICAL EXAM: Blood pressure 98/70, pulse 72 and regular, respiratory rate 18. The patient describes headache at 8/10, although does appear very comfortable while talking to me. No carotid or orbital bruits. There is no orbital tenderness. Temporomandibular joint is nontender. Temporal pulsations are normal. There is full range of neck movement but no tenderness. Temporal artery pulsations are normal and nontender. There are no rashes, ulcers or joint effusions noted. Cranial nerve examination is unremarkable with normal fundi and normal visual fields. Pupils are symmetric and reactive. Extraocular muscle movements are full without nystagmus. Visual fields are full. There is no facial weakness. Tongue is midline. Palate elevates symmetrically bilaterally. Hearing to bedside testing is normal. Shoulder shrug is normal. Motor examination reveals no tremors or myoclonus or focal weakness. Gait is normal. Sensory examination is unremarkable. Cerebellar testing and finger-to-nose is normal. Deep tendon reflexes are 1+ throughout and toes are downgoing bilaterally.
PHYSICAL EXAMINATION: This is a pleasant (XX)-year-old female who is currently sleeping comfortably in her hospital bed. The patient is easily arousable, alert and answers questions appropriately. She is a little bit difficult to understand. She does have some history of expressive aphasia. The patient is not significantly dyspneic on conversation or on lying supine. Vital Signs: Blood pressure is 102/43, heart rate is 95, respiratory rate 19 and saturating 96% on nonrebreather. Skin: Warm and dry. Lower extremities: There is significant burn scarring and skin grafting visible. The patient does have her right lower extremity bandaged secondary to chronic ulcerations. HEENT: Head is normocephalic and atraumatic. Pupils equal, round and reactive to light. Extraocular movements are intact. Oropharynx is without erythema or exudate. Neck: Supple with no thyromegaly or lymphadenopathy. Lungs: Breath sounds are slightly diminished on the left base, however, without significant rales or rhonchi. There is audible expiratory wheezing. Heart: Apical impulse is at the midclavicular line and brisk. There is no elevation of the JVP at 30 degrees. Carotids are brisk, 2/4 bilaterally. There are no significant bruits heard. Heart is regular rate and rhythm. Normal S1 and S2. No significant murmurs, rubs, gallops or extra heart sounds appreciable. Abdomen: Soft, nondistended, nontender x4 quadrants. There are audible bowel sounds. There are no palpable masses. Peripheral Vascular: Radial and femoral pulses are palpable. There are no appreciable femoral bruits. Posterior tibial pulses cannot be palpated on the right lower extremity secondary to bandaging. Pedal pulses are diminished in the left lower extremity. Extremities are warm without clubbing, edema or cyanosis. Musculoskeletal: Unremarkable. Neurologic: The patient is alert and oriented to person, place and time. The patient moves all four extremities. Face is symmetric.