CHEST: Decreased breath sounds at both bases. Trachea is midline. No nystagmus is noted. Has some increased tone at the neck. ABDOMEN: Soft, nontender, and nondistended. SKIN: Normal color, turgor and temperature. GENERAL: The patient is a thin, well-developed (XX)-year-old female looking her stated age in no acute distress. Face is symmetric. CARDIOVASCULAR: Heart has regular rate and rhythm. Has absent vertical upward smooth pursuits. Log roll was negative bilaterally. HEART: Regular rate and rhythm. No hepatosplenomegaly. Weight is stable with a mild weight gain secondary to hormone use. rdTenderness of right 3 to 4th interspace. VITAL SIGNS: Blood pressure 114/74, pulse 78, respiratory rate 21, temperature 98.4, pulse ox 98% on room air. ABDOMEN: Normal. Vibratory sensation is reduced in distal lower extremities. Trachea is midline. There was no new abnormality. GENERAL: The patient is an obese lady, lying down on the bed, not in any acute distress. CHEST: There was a well-healed midline scar without any tenderness to the chest wall. No wheezes, rales or rhonchi. BREASTS: There was no gynecomastia. PHYSICAL EXAMINATION: General Appearance: This is a (XX)-year-old female, who answers questions appropriately and currently is in no apparent distress. Pharynx is grossly clear with pink, moist mucous membranes with the exception that her right tonsil is enlarged and erythematous with some exudate present. No wheezing. She has no tenderness to palpation around her eyes. HEART: Regular rate and rhythm without murmur. The trachea is midline and no mass is palpated in the neck. The patient also has sensory changes in the right lower extremity from the mid brachioradialis down. She is only able to name 2 of 6 objects presented to her. No palpable masses. HEENT: Normocephalic and atraumatic. No masses, no hernias, no rebound, no guarding. Has very mild dysarthria, especially for pharyngeal consonants. GENERAL: The patient appeared to be in no distress. Smooth pursuit movements are similarly slowed and have some saccadic breakdown in the horizontal plane. GENERAL: The patient is in no acute distress. Skin: Warm and dry without any rash. There was no evidence of gum bleeding. The right eyelid is closed; she is able to open it. VITAL SIGNS: On admission to the ED today, temperature is 98.4, blood pressure 152/74, pulse 86, respiratory rate 16, O2 saturations 99% on room air. They appear to be very involved in her care. There is also a small laceration over his forehead. Motor exam reveals patient’s left upper extremity to be 5-/5 proximally and 4/5 distally with increased tone. NEUROLOGICAL: Gross nonfocal. Coordination: The patient normally performs finger-to-nose-to-finger testing with the left but it is mildly impaired on the right due to weakness. Sclerae are anicteric. Pupils were equally reactive to light. No carotid bruits. LUNGS: Clear to auscultation bilaterally. Surrounding one of the ulcerations, right infraumbilical region, is significant edema and erythema, which expands in a band-like distribution along the belt line across the right lateral abdomen to the midaxillary line level. Her left eye was tested. Sensations are normal, tenderness with palpation of the right great toe. Both pupils are equal, reactive to light and accommodation. She has no evidence of hyphema and has no evidence of retained foreign body. SKIN: No skin rashes or lesions are noted. EXTREMITIES: No edema or cyanosis. No calf tenderness. LUNGS: Air entry was good. Skin is warm and dry with good palpable pulses and good capillary refill. Oropharynx shows cleft palate repair. LUNGS: Clear to auscultation bilaterally. intake, however, over the last 2-3 days. Heart sounds are normal without click or murmur and distal extremities have easily palpable pulses with good skin temperature and tone. Tympanic membranes clear. No significant nystagmus is present. Extraocular muscles intact. There are no loose teeth. I was unable to appreciate any clonus in this patient. LUNGS: Normal symmetrical expansion of both hemithoraces. Trachea is midline. EXTREMITIES: The patient had swelling of both his legs. Pulses intact in the right lower extremity. ABDOMEN: The patient was morbidly obese. Muscle bulk, strength and tone are grossly intact with some focal discrepancies in the right hand with regard to specific groups. ABDOMEN: Slightly obese. There was a wound that was draining some yellowish drainage on the left lower leg. Neurologic: No focal deficits. There is no orbital stepoff or deformity. NECK: Supple. Pupils are equal, round and reactive to light. Abdomen: Obese, soft with obvious inflammation focused within the right subumbilical area. Head and Neck: He is normocephalic and atraumatic. She does have upgoing toes on the left. Fundi are without papilledema, hemorrhages or exudates with normal vessels. GENERAL: This is a well-appearing (XX)-year-old man in no acute distress. GENERAL: Well-developed, well-nourished female in some discomfort, but no acute cardiopulmonary distress. Strength 5/5 throughout with tone and bulk with the following exceptions, 4+/5 intrinsic muscles of the hands and feet, no involuntary movements noted. She does have some anterior chain cervical lymphadenopathy. Normal finger to nose testing and normal gait. She is cooperative with the exam. Mucous membranes are moist. Conjunctivae and EOM are normal. NEUROLOGIC: Higher Cortical Function/Mental Status: The patient is alert. ABDOMEN: No abdominal masses or bruits. By using this site, you agree to the use of cookies. Extremities: No finger cyanosis or leg edema. No scleral icterus. PSYCH: Normal mood, normal affect. Arm swing is normal. SKIN: No ulceration or induration present. There may be a rub and murmur, but it is somewhat difficult to discern from the additional heart murmur that is generated by the presence of an AV fistula. ABDOMEN: There is no pain, no tenderness, no distention and no organomegaly. Motor: Has full strength and normal tone in the extremities. No rhonchi. HEENT: Atraumatic and normocephalic. Trachea is midline. Sclerae anicteric. Visual acuity was tested and is 20/50. Jugular venous pressure is normal. NEUROLOGIC: High Cortical Function/Mental Status: The patient is alert. No cranial or cervical bruits. When she stands on her own, she looks very unsteady and tends to have a widened base. GENERAL: The patient is awake, alert and oriented, in no acute distress. Remainder of the cranial nerves are intact and symmetrical. LUNGS: Decreased air entry bilaterally. He appears well-developed and well-nourished. LUNGS: Revealed decreased breath sounds at the bases. No masses detected. She does have bilaterally enlarged tonsils, which she states is baseline for her, but no difficulty or pain with swallowing. Sclerae nonicteric. He does have an area of purpura over his left periorbital area. She has spontaneous retropulsion. Regular rate and rhythm. NEUROLOGIC: Intact. She has no sublingual swelling. Pupils equal, round and reactive to light. Abdomen: Soft, nontender, nondistended in all quadrants. Breathing is not labored. Vibratory sense appears to be diminished in the left toe to the level of the left knee. Eyes: Anicteric pupils symmetric, extraocular motion intact. The nares are patent. LUNGS: Clear to auscultation. PHYSICAL EXAMINATION: The patient has a left carotid bruit. Extraocular muscles are intact. There is no trismus. VITAL SIGNS: T-max was 100, currently 97.5, blood pressure 110/60, respirations 22, and heart rate 88. Extraocular movements are intact. No wheeze. Buccal mucosa moist, no lesions. She does have tenderness to deep palpation at the right low back and into the top of her gluteus muscle on that right side. LUNGS: Clear to auscultation bilaterally. PHYSICAL EXAMINATION: HEAD AND NECK: Head is normocephalic and atraumatic. Body mass index: 25.67 kg/(m^2). She does have a very tender 2 x 2 cm lymph node in her right anterior cervical chain that is freely mobile. Surgical scar from vein harvesting for coronary artery bypass graft surgery present. EXTREMITIES: No cyanosis, clubbing or edema. HEENT: Normocephalic and atraumatic. Abdomen: No tenderness. She has a better-than-average fund of knowledge. Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring. Extraocular movements intact. No rebound or guarding noted. PHYSICAL EXAMINATION: The patient is alert and oriented to person, place and time. The thyroid is normal to palpation. No murmurs, rubs, or gallops. PHYSICAL EXAMINATION: Temperature 98.4 degrees, pulse 84, respirations 18, blood pressure 110/72. There was full range of motion in all the extremities. The head and neck are nontender without thyromegaly or adenopathy. The patient has mild bradyphrenia and also frequently gets off topic and has some difficulty answering questions clearly. No organomegaly. You also have the option to opt-out of these cookies. Extraocular movements are intact. The patient has upgoing toes bilaterally. Neck: Supple. NECK: Supple, no lymphadenopathy, no thyromegaly. Extraocular movements are intact. Pulse noted to range from as low as 36 beats per minute to above 62 beats per minute. Whether you are looking for essay, coursework, research, or term paper help, or with any other assignments, it is no problem for us. Eyes: Extraocular muscles were intact. LUNGS: Clear to auscultation. NEUROLOGIC: Alert and oriented x3. EXTREMITIES: Distal pulses 2+ bilaterally. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. • NCAT = normocephalic, atraumatic • PERRL = Pupils Equal Round and Reactive to Light • Erythema = redness • Exudate (tonsilar) = most commonly white spots on the tonsils, but can be any fluid or cellular matter deposited on any tissue • Purulent = consisting of pus • … Patient has had poor p.o. Skin: No rash. GCS is 15. There are no cortical sensory signs and graphesthesia and stereognosis intact bilaterally. Negative Spurling test. GENERAL: The patient is lying comfortably in bed. Knee exam showed no tenderness or swelling. Vital Signs: Her blood pressure is 142/74, heart rate is 72, respiratory rate is 22, saturation 98% on room air, currently afebrile, temperature 98.2. Extraocular muscles are intact. MUSCULOSKELETAL: Normal gait and grossly nonfocal. Visual fields full OU. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. GENERAL: The patient is awake and alert. Sclerae anicteric. Extraocular muscles are intact. Palate elevates symmetrically and tongue is in the midline. NECK: Supple. Physical Exam: Glucoses have been within normal limits. There is no costovertebral angle tenderness. Does a great deal of mumbling in between, can get her to answer questions at times appropriately. Extraocular movements are intact. HEENT: Head is normocephalic and atraumatic. ABDOMEN: Mildly distended but soft. SKIN: Warm and dry with no evidence of rash. NECK: Supple. Neurological: The patient is oriented to person, place and time. LUNGS: Clear. No papilledema or hemorrhages are seen. Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact. NECK: Supple. The neck is supple. He is in no acute distress. VITAL SIGNS: Blood pressure 112/64 in the right arm, pulse 72 and regular, respirations 18, weight 132 pounds, temperature 98.4 degrees. LUNGS: Rare basilar crackle bilaterally. NEUROLOGICAL: Appears to move all extremities and this exam is only pertinent for confusion at this time. The patient was able to name the current president only. He had an ileostomy that was functioning.
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