PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 140/74 and heart rate 62 and regular.
GENERAL APPEARANCE: The patient is a well-developed, well-nourished male in no acute distress. He has obvious right-sided weakness. His answers are quite slow but appropriate. He is alert and cooperative.
HEENT: Head: Negative. Eyes: EOMs are intact.
NECK: Without JVD. Carotid pulses are 2+ and equal. There are no bruits appreciated.
HEART: Regular rhythm. There is an S4. There is no S3 or murmur. PMI is not palpable.
LUNGS: Clear, but he really cannot cooperate well with the examination.
BACK: There is no presacral edema.
ABDOMEN: Large, soft, and nontender. No palpable masses or organomegaly. Bowel sounds are active. There is no abdominal bruit.
EXTREMITIES: He has 1+ edema on the left, none on the right. Femoral pulses are 2+ and equal without bruits. Dorsalis pedis pulses are 2+ and equal.
PHYSICAL EXAMINATION: VITAL SIGNS: P is 148/78, heart rate is 92, and respirations 22. HEENT: Carotid pulses were 2+ with normal upstroke without bruit. Right carotid artery endarterectomy scar is noted. LUNGS: Diminished breath sounds diffusely without audible wheezes or rhonchi. HEART: Tones are decreased. There is a regular rhythm. No audible gallop or murmur appreciated. PMI is not palpable. ABDOMEN: Markedly obese. There is no palpable tenderness. Femoral pulses were 1+, no audible bruit. EXTREMITIES: Dorsalis pedis pulses 2+ on the right, weak on the left. Posterior tibial pulses are not palpable bilaterally. There is no pedal edema at this time.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 78, blood pressure 114/52, respiratory rate is 22, and temperature afebrile.
GENERAL: The patient is a pleasant Hispanic female in no apparent distress, except for slight tachypnea.
HEENT: Pupils are equal and round. Mucosa and conjunctivae are pink.
NECK: No increased JVD.
CHEST: Bibasilar rales.
CARDIAC: PMI is not palpable. S1 and S2 are normal. Grade 2/6 holosystolic murmur at apex.
ABDOMEN: Soft. Nontender. No hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, 2+ pedal edema. Denies dorsalis pedis pulses.
PSYCHIATRIC: Oriented x3.
PHYSICAL EXAMINATION: Examination of the head reveals a laceration in the occipital region, sutures in place. Examination of the eardrums reveals no hemotympanum, reveals them to be intact bilaterally. No raccoon eyes or Battle sign. The patient does have infraorbital ecchymosis on the right eye. No ocular involvement. The patient does have tenderness in the right TMJ as well. Was unable to completely open mouth secondary to pain. None of his teeth are loose on examination. The patient does have abrasion on the bridge of the nose as well as the right side of the nose with some soft tissue swelling as well. No septal hematoma noted within. The patient is alert and oriented x3. The patient has normal remote memory, but short-term memory surrounding the event is not present. Neurologically, cranial nerves II through XII are grossly intact. DTRs are 2/4 in the upper and lower extremities.
PHYSICAL EXAMINATION: The patient is well built, well nourished, not in any distress. He is 5 feet 8 inches tall, 230 pounds. Vital signs are within normal limits. Head and neck examination was normal. Cranial nerves are intact. Cardiovascular exam was within normal limits. Lungs are clear on auscultation. Abdomen is obese. In the lumbosacral area, there is diffuse tenderness in the right gluteal area medially. No definite tenderness or tender point or trigger point identified. Gait is normal. The patient can stand on toes and heels. Motor and sensory exam was not significant. Deep tendon reflexes are symmetrical and equal. Straight leg raise test was negative. Patrick’s negative bilaterally. Lumbar spine flexion is limited to 40-45 degrees. Extension is 15 degrees with some pain. Right and left bend was within normal limits.
PHYSICAL EXAMINATION: The patient is alert and oriented x3 and in slight distress secondary to pain. Head: Normocephalic and atraumatic. Eyes: Pupils equal, round, and reactive to light and accommodation. Extraocular muscles intact. Sclerae, conjunctivae, and fundi are clear bilaterally. Ears: There is cerumen present in both canals. Nose and Throat: Pink, moist, and clear. Cervical Spine: There is no tissue texture change, spasm, or tenderness noted. Range of motion, neurologic, and vascular status intact. Lumbosacral Spine: There is moderate ecchymosis and tenderness from the mid sacral region to the coccyx extending to the left sacroiliac region. Forward bending is approximately 80 degrees. Heel and toe walk intact. Motor 5/5. Deep tendon reflexes 2/4. Straight leg raise causes low back pain at approximately 10 degrees of hip flexion bilaterally. Figure-of-four causes low back pain bilaterally. Neurologic: Cranial nerves II through XII, sensory and cerebellar function intact. Motor in the upper and lower extremities 5/5. Deep tendon reflexes are 2/4. Romberg negative.
PHYSICAL EXAMINATION: On physical exam, the patient appears his stated age and has mesomorphic body habitus, appears in no acute distress. Head, neck, and upper extremities are grossly normal and symmetric. As we travel down his lower back, there is some bilateral pain. In lumbosacral area, there are tight muscles bilaterally, some tenderness over the spinous processes. SI joint exam is essentially negative. Reflexes are intact bilaterally. There is positive straight leg raise on the right at only 20 degrees, negative on the left. Patrick maneuver is equivocal.
PHYSICAL EXAMINATION: He appears about his stated age. He is in no acute distress. He is moderately overweight. HEENT: Grossly normal. Neck grossly normal. Upper extremities are symmetrical. No evidence of muscle wasting or asymmetry. Thoracic spine is nontender. As we move to the lumbar area, there is some tightness, especially along the right side of the lumbar area. It does not reproduce the patient’s pain, however, and his predominant complaint is not actual back pain. He is not particularly tender over the spinous process line, the facet joint line, or in the area of the SI joints. Positive straight leg raise on the right at only 10 to 20 degrees, negative on the left. He appears to have intact sensation and good strength on both legs. He tolerates Patrick maneuvers well without reproducing his pain and flexion, extension, and rotational movements of the back are tolerated reasonably well. The patient does walk with a significant limp, however.
PHYSICAL EXAMINATION: The patient appears to be a pleasant woman, communicates very well, moves around in bed. She is grabbing on her right lumbar area due to pain. On palpation, there is discomfort there. Further examination of the back revealed no acute deformity or tenderness over the lumbosacral junction or over the sciatic notch. Straight leg raising indicates slight bit of hamstring spasm when leg is raised beyond 60 degrees. Hip, knee, and ankle motions are fine. No motor or sensory deficits identified. The deep tendon reflexes are difficult to elicit, including the knees and over the ankles.
PHYSICAL EXAMINATION: On exam, the patient is a very pleasant gentleman in no acute distress. He is about 5 feet 6 inches and weighs 210 pounds. His gait is nonantalgic. His tandem walk is normal. HEENT: Normocephalic and atraumatic. Pupils equal and reactive to light and accommodation. Extraocular movements are intact. Oropharynx is clear. Neck is supple. No adenopathy. Chest is clear to auscultation. S1 and S2 without gallops or murmur. Abdomen is obese and nontender. A left-sided transverse incision is noted. Incisional hernia is present. It does not appear to be strangulated or incarcerated. Spine exam demonstrated tenderness in the lumbosacral junction, posterior-superior iliac spine. Tenderness was increased on bilateral facet-loading maneuver. Flexion is complete, but this is met with symptom provocation. The patient experienced pulling on Lasegue maneuver. Straight leg raise is negative for radicular pain. Extremities show no clubbing or cyanosis. Peripheral joint range of motion reduced. Neurological evaluation is noted for diminished deep tendon reflexes. The rest of the neurologic exam is normal.
