Saturday, November 25, 2006

Physical Examination (PE)


VITAL SIGNS: Temperature, pulse, blood pressure, respiratory rate, weight, and height. Oxygen saturation on room air is 96%. Afebrile.
GENERAL: Alert, cooperative (age/gender) in NAD. Reveals a well-developed, well-nourished, well-hydrated male in no acute distress. Sitting comfortably on the examining table. Normal affect. Cachetic. Appearing alert and comfortable; looks normal self. The patient is awake, alert x3 in no acute distress.
SKIN: Normal. No rash, ecchymosis, erythema or drainage. No hematoma. No cyanosis. No lesions.
HEENT exam: Unremarkable. Reveals the head to be normocephalic and atraumatic. Eyes: PERRLA; EOMS are intact bilaterally; red reflex is also present bilaterally. Fundoscopic examination is unremarkable for hemorrhages, exudates or papilledema. Sclera is white. Conjunctiva is pink. Extraocular muscles: Intact. Sclera is anicteric. Ears: Clear. TMs are pearly gray with good cone of light. TMs erythematous, bulging bilaterally and poorly movable to pneumatic otoscopy. TMs were clear. TMs are dull, retracted.
Nose: Nasal passages pink and moist, clear (free) rhinorrhea. Throat: Beefy red, no exudates. Clear and free of erythema. Strep test is positive. Buccal mucosa is pink and moist as is the tongue. Posterior pharynx was normal. Facial musculature is atrophic with considerable amount of atrophic changes around the lips, cheeks, and gums.
NECK: Supple with shoddy cervical lymphadenopathy. Trachea is midline. Carotid arteries negative for bruits bilaterally. No tenderness to palpation over the bony prominences of the cervical spine. No nuchal rigidity or meningeal signs. There is no JVD. No thyromegaly or JVD, carotids 2+, no bruits. Neck is obese. Neck veins are difficult to assess. Neck veins are nondistended. Carotid impulses were normal although the right side exhibited a louder systolic murmur to the left. There is no thyromegaly. Neck veins are flat. The carotids are quiet. Neck is supple, JVD is not appreciated. Thyroid is not palpable. Denies neck swelling.
HEART: NSR without murmur. RRR. Regular rate and rhythm. S1 and S2 without murmurs. Normal S1 and S2, without murmur, gallop, click, or rub. PMI is poorly palpable. Heart tone is somewhat distant. There is an S1 and S2, no S3, soft murmur. Audible heart tones with a grade 1/6 systolic murmur. Regular cardiac rhythm with a fourth heart sound and a grade 1/6 systolic ejection murmur at the base without radiation.
Cardiac examination revealed an impalpable apical impulse, a normal S1 and S2 with normal intensity, splitting not heard, and a grade 2/6 mixed frequency midsystolic murmur of the base in the left sternal border. No diastolic murmur or gallop. Cardiac exam reveals a regular rhythm with no murmurs or gallops. Cardiac exam: S1 and S2, irregular rhythm.
LUNGS: Clear to auscultation and percussion with some upper respiratory rhonchi with expiratory wheeze, rales at the bases. No tenderness to AP and lateral compression of the chest wall. Diaphragmatic excursion is nominal. Has tenderness to palpation over the left chest especially anteriorly. No adventitious sounds. Lungs are clear with a reasonably good air exchange.
ABDOMEN: Soft, nontender. No appreciable masses (or no masses noted). No organomegaly. Bowel sounds present in all four quadrants. They are normoactive. No hepatosplenomegaly, masses, or tenderness. Benign without organomegaly. The abdomen was obese and detected no organomegaly.
External genitalia was normal. Vaginal cuff was normal. No pelvic masses or tenderness.
RECTAL EXAM: Rectum had some external or slightly inflamed hemorrhoids. Internally, no masses, brown heme negative stools.
EXTREMITIES: No edema, good peripheral pulses. Within normal developmental limits, symmetrical without edema. Show rheumatoid type remodeling, considerable atrophy of the muscles, swelling of the hand. There is trace 1+ edema. Extremities exhibited no clubbing and cyanosis and pedal pulses were not detected. Good capillary refill.
BACK: No palpable tenderness on the thoracolumbar paraspinous musculature on the left. No spasm. No midline tenderness, crepitus, or stepoff. Able to stand on his toes. Able to stand on his heels and do deep knee bend. Good patellar and Achilles reflexes. Good sensation in the lower extremities. No tenderness over the spine itself; hip flexion-extension is preserved. Interestingly enough, right medial quadriceps is atrophied as compared to the left side but its strength is preserved. No pain with either straight leg raises, ankle flexion-extension, eversion and inversion are all preserved. Sensation to light touch, pin prick, and vibration is intact. Pulses are normal.
NEUROLOGICAL (or CNS): CN 2 through 12 are grossly intact as are motor and sensory sub-systems.
The remainder of examination is essentially nominal. CNS is nonfocal. Neurological examination does not reveal any focal or lateralizing deficits. Funduscopic examination is unremarkable. No evidence of afferent pupillary defect or nystagmus; otherwise, II-XII intact.
MOTOR EXAM: 5/5. Normal bulk and tone. 5/5 in left upper extremity and bilateral lower extremity, 4/5 right toe dorsiflexion. Right upper extremity reveals cortical hand with flexed fingers in a grip position, biceps and triceps is 4/5, deltoid is 5/5. She cannot extend her fingers.
REFLEXES: 2+. Toes are downgoing. 3+ in right upper extremity and lower extremity, 2+ left upper extremity. Right toes are upgoing. Left toes are downgoing.
COORDINATION: Intact, other than right upper extremity which revealed dysdiadochokinesis.
GAIT: Steady. Reveals right foot drop which is mild; otherwise, steady.
Exam is stable and is documented in the office record.
MENTAL STATUS EXAM: Alert and oriented x3. No tics or dyskinesias. Mood: Reported as “not very good.” Affect was tearful. No suicidal or homicidal ideation.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is alert and oriented x3. VITAL SIGNS: Temperature is 97.8, pulse is 75, respirations are 18, and blood pressure is 160/85 on presentation. Oxygen saturation is 96% on room air. SKIN: Warm, dry, no rash. HEENT: Normocephalic and atraumatic. No perioral or periorbital edema. Eyes: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Conjunctivae sacs are injected. The ears, nose, and throat are clear. NECK: Supple. No adenopathy or meningeal signs. No meningismus. CHEST: LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, without murmurs. ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds. No visceromegaly. SKIN: Moist. Good turgor without any rash, petechiae, bullae, or purpura. NEUROLOGIC: Cranial nerves II through XII are grossly intact without focal or neurologic deficits. EXTREMITIES: No clubbing, cyanosis, or edema. Distal neurovascular functions in the legs are maintained. Legs are very thin. There is no calf or popliteal involvement. Achilles unremarkable. Foot exam normal bilaterally. No specific tenderness on the right ankle was identified or has “soreness” on both ankles. Smooth range of motion noted. Ankle and knee joints are cool. No overlying erythema, evidence of trauma, evidence of DVT, or infection. Knee joints are within good range of motion as well although, they “ache.” No gross laxity or effusion noted.

PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a delightful, pleasant 26-year-old who is alert and oriented to person, place, time, and purpose, and appropriate for situation. VITAL SIGNS: Blood pressure 120/80 initially with a recheck of 115/70, pulse 85 and regular, weight 145 lbs which is stable. HEENT: Conjunctiva clear, no exophthalmos. Mucous membranes are pink and moist. NECK: No thyromegaly, jugular venous distention or carotid bruits. LUNGS: Equal and symmetrical expansion, clear throughout to auscultation. Cardiac: Audible S1 and S2. No murmurs, rubs or gallops appreciated. ABDOMEN: Nontender. EXTREMITIES: Radial pulses 2+ bilateral. Posterior tibial pulses 2+ bilateral. No peripheral edema. No clubbing. SKIN: No cyanosis.

PHYSICAL EXAMINATION: Temperature is 98, pulse 60, respirations 20, blood pressure is 130/80, Oxygen saturation is 96%. Peak flow is at 145 prior to nebulizer treatment in the office today. Speech is sluggish but normal. Skin is warm and dry. Color is pinkish tan. Turgor is good. HEENT: TMs are dull. Nares are patent with pink turbinates. Posterior oropharynx: Slightly injected. Oral mucosa: The patient has erythema to the roof of the mouth, several missing teeth, several with really bad gingivitis. Neck is supple with enlarged lymphs in the anterior cervical chain, none in posterior. No thyromegaly . Chest: Heart rate is regular. Lungs are clear to auscultation. Respiratory rate is regular. Chest expansion is equal bilaterally. No sternal or axillary node is palpable. Report pain at a level 7-1/2 in his leg and the head.

PHYSICAL EXAMINATION: Afebrile. Weight 130 pounds, temperature 99.7, heart rate of 100, blood pressure 120/70, oxygen saturation 94% on room air. In general, this is a thin, teary-eyed patient, alert, pleasant, in no apparent distress. Neck veins are flat. Lungs are clear. Heart S1, S2. On S1 and S2, evidence of pectus excavatum noted with anterior chest wall deformity. Lungs: Rhonchi present bilaterally, no crackles, no wheezes. Exam of nostrils: No obvious evidence of polyps, but with evidence of deviated nasal septum noted. Cardiovascular exam is normal. Pelvic exam: Visual exam of the vulva and perineal area was done only. The patient has multiple vesicles noted at the perineum with several scattered papules over the labia majora. Abdomen is soft, nontender. Extremities: No edema. (Trace ankle edema.)

LABORATORY: Basic metabolic panel, free T4, and TSH which are currently pending. Urinalysis does reveal 1+ leukocytes, positive nitrites, 1+ protein, trace of blood, 1+ ketone, 1+ bilirubin, remainder negative. Urine pregnancy test is negative. LCR is currently pending. CBC: Normal except for white count of 4300. Pancreas metabolic profile: Normal. Total cholesterol 167 with HDL 69, LDL 75. WBC count today is 8.8 with a 73/27 differential. QBC is in the chart. Remainder of the examination is essentially nominal. Chemistries: Creatinine has gone up. The rest seems to be stable.

RADIOGRAPHIC EXAMINATION: Shows increased broncho-pulmonary markings, bronchial wall cuffing, infiltrates bilaterally. Review of previous x-ray does show what appears to be two fractures on the anterior ribs. Previous film was read for congestion.

Electrocardiogram: EKG demonstrates sinus rhythm. Inferior and lateral ST depression and without significant change compared with previous EKG.
A 12-lead electrocardiogram today demonstrates a sinus rhythm at 70 bpm with left anterior fascicular block and nonspecific intralateral ST-T wave changes.

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