PHYSICAL EXAMINATION: GENERAL: Reveals an overweight-looking woman in no apparent distress. HEENT: Atraumatic and normocephalic. NEUROLOGICAL: Examination reveals normal orientation, attention, and language skills. Cranial nerve examination reveals full visual fields. Extraocular movements are intact. There is no nystagmus. No diplopia. Pupils are full, minimally reactive to light, and symmetric. There is no facial asymmetry. Tongue was midline and palate is symmetric. Funduscopic examination was unremarkable without any evidence of papilledema. Motor examination of the extremities did not reveal any focal weakness. Deep tendon reflexes are 1+ bilaterally and symmetric. Plantar responses are flexor. Coordination is intact with finger-to-nose testing. Gait is deferred.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 144/80, pulse 78, respirations 18, temperature 97.8, and pulse ox on room air is 100%
GENERAL: This is a well-developed, well-nourished Hispanic female in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. Nostrils are clear. The patient has macerated abraded skin under the right nostril and extending to the nasolabial fold. There is no erythema or induration, no evidence of preseptal cellulitis. There is no purulent drainage appreciated. No vesicles.
NECK: Supple without lymphadenopathy.
LUNGS: Exhibit diffuse end-expiratory wheezes without focal rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
CHEST: Respirations easy and unlabored.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Warm, dry and intact.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and unresponsive, in no acute distress.
VITAL SIGNS: Temperature 100.4, respiratory rate 24, heart rate 80, and blood pressure 166/52.
HEENT: Pupils are equal and reactive to light. No discharge from nose or ear.
NECK: There is scar in the neck suspicious for previous tracheostomy. No masses were noted.
LUNGS: Rhonchi bilaterally, more on the left side.
HEART: Regular rate and rhythm. No murmurs.
ABDOMEN: Distended and soft. Bowel sounds are hypoactive. PEG tube in place.
EXTREMITIES: Contracted and deformed. No edema.
NEUROLOGIC: The patient was unresponsive.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 124/92, pulse 82 and regular.
GENERAL: The patient appears well developed, well nourished, in no acute distress. Alert and oriented x3.
HEENT: No scleral icterus or conjunctival pallor. Extraocular movements intact. Pupils equal, round, and reactive to light. Throat clear, no lesions or exudate.
NECK: Supple. No palpable lymphadenopathy, mass, jugular venous distention.
LUNGS: Clear to auscultation and percussion.
HEART: Regular rate and rhythm. Positive S1, S2. No appreciable murmurs or gallops.
ABDOMEN: Mild lower tenderness, but no guarding, rebound, or palpable organomegaly or masses.
RECTAL: Hard stool in the rectum with no significant external hemorrhoids, fissures. The anal sphincter tone is normal, and there is no obvious stricture or palpable masses or tenderness.
BACK: No costovertebral angle or spinal tenderness.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Cranial nerves II-XII, motor, sensory grossly intact.
MUSCULOSKELETAL: No gross joint deformity.
SKIN: No rashes, hives or stigmata of chronic liver disease appreciated.
PHYSICAL EXAMINATION: On examination, she is able to toe walk and heel walk. She stands with a slight list to the left. She has tenderness in the mid to lower lumbar area, both sacroiliac joints, and sciatic notches. She can forward bend 70 degrees with a moderate list to the left. Backward bend to 10 degrees. Lower motor exam reveals about 50% weakness of the left foot dorsiflexors, normal plantar flexion, about 30% weakness of the left quadriceps and hamstrings. Sensory exam is normal. Reflexes at the knees are 2+/2+, at the ankles 1+/1+. She can straight leg raise to 80 degrees on the right but only 45 degrees on the left. Her thigh circumference is 1 inch smaller on the left. Her calf circumference is equal on both sides. Her left ankle exam reveals some fullness over the anterior and lateral aspects of the joint with tenderness over the anterior joint line and anterolateral ligaments. There is some limitation of motion. The patient can plantarflex 40 degrees on the right, only 30 degrees on the left, dorsiflex 15 degrees on the right, 3 degrees on the left. Inversion is 30 degrees on the right, 25 degrees on the left, and eversion is 25 degrees on the right, 0 degrees on the left. She has a positive anterior drawer sign on the left and a 2+ positive talar tilt.
PHYSICAL EXAMINATION: Neurologic examination at this time finds the patient to be cheerful and cooperative. He is fully alert and oriented and able to render his history in precise and detailed fashion. Speech and language are unimpaired. Optic disks flat. Extraocular movements are full without nystagmus. Pupils are equal, round, and normally reactive to light and accommodation. Eye closure, facial expression, tongue, palate, sternocleidomastoid, and trapezius function normally. Deep tendon reflexes 1+ throughout. Babinski signs are absent. Motor power testing fails to disclose any atrophy, wasting, or fasciculation. Strength is normal in all groups. Tone is normal throughout. Sensory testing finds an intact symmetric perception to pin, touch, and temperature. There is no extinction to double simultaneous tactile stimulation. Position sense is intact. Cerebellar testing finds finger-to-nose done normally. Neck is supple. The patient was not ambulated.
PHYSICAL EXAMINATION: The examination reveals that the patient is an attractive woman. Examination of the periorbital area reveals upper lid dermatochalasia with mild brow asymmetry between the left and right brows. Examination of the lower lids reveals puffiness in the appearance of her lower lids and creases within the lower lids that are accentuated by smiling. In addition, when she smiles, on the left, there is an isolated herniated fat pad, which is seen more prominently on the left side than the right. This would be the middle fat pad. Globe pressure does show herniation of all three fat pads. There is a mild tear trough deformity present. The patient has presence of some crow’s feet at rest and also pretarsal creases present. The patient has mild glabellar creases at rest and three horizontal deep frontalis creases that do not completely eliminate with skin distraction. The cranial nerve VII appears intact bilaterally. The skin is thick, and the lower lid skin also seemed to be somewhat thick and edematous.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake, alert, oriented, in no acute respiratory distress.
VITAL SIGNS: T-max was 98.6, respirations 20, and blood pressure 110/68.
HEENT: Pupils reactive to light and accommodation. Conjunctivae and sclerae clear. No jaundice. No conjunctivitis.
LUNGS: Clear to auscultation.
HEART: S1 and S2 within normal limits. No gallops, rubs, or murmurs. No heaves, thrills, or lifts.
ABDOMEN: Soft and nontender. No masses.
EXTREMITIES: Lower extremities are within normal limits. No cords. No swelling. The right hand revealed marked swelling on the dorsum of the hand between the first and second metacarpal area. No open wounds. No significant erythema. There was minimal tenderness on palpation. There was also some edema with no streaking over the palmar aspect of the right hand at the first and second metacarpal areas. No open wounds were noted.
PHYSICAL EXAMINATION: The patient has a dorsal hump deformity. The take-off of her nose at the glabella is relatively superiorly located. There is a dorsal hump deformity that appears to be composed of a combination of bone and cartilage. Intranasal examination revealed a slight septal deviation to the right, although, patent airways bilaterally. There is no evidence of septal perforation. Her nasolabial angle is approximately 90 degrees. The patient has localized adiposity of the bilateral outer thighs with associated mild cellulite. There is also a small dog-ear on the right lateral abdominoplasty scar.
PHYSICAL EXAMINATION: On physical examination, he is afebrile, nontoxic, well appearing, in no apparent distress. HEENT: Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. Oropharynx is clear without exudates. Neck is supple without lymphadenopathy. Heart: Regular rate and rhythm. No murmurs, gallops, or rubs. Lungs: Clear to auscultation bilaterally. No wheezing, rhonchi, or rales. Abdomen: Soft, nondistended, nontender. Bowel sounds are present. Extremities: No clubbing, cyanosis, or edema. Skin: No rash or other skin lesions. Neurologic: Grossly nonfocal.
PHYSICAL EXAMINATION:
GENERAL: A well-developed and well-nourished (XX)-year-old Hispanic male resting comfortably in bed at this time, in no acute distress.
VITAL SIGNS: Blood pressure 178/96, pulse 72 and regular, respirations 14 and unlabored, and temperature afebrile.
HEENT: Normocephalic and atraumatic. Conjunctivae are pink. Sclerae anicteric. Pupils are equal, reactive to light and accommodation. Extraocular movements are intact. Ears, nose, and throat are clear. Mucous membranes of the oropharynx were slightly dry.
NECK: Supple without adenopathy or thyromegaly. There were bilateral carotid bruits.
CHEST: Symmetrical. There is a well-healed sternotomy scar.
LUNGS: Grossly clear to percussion and auscultation.
HEART: Normal sinus rate. S1, S2, and S4 are present without thrills, murmurs, or extra sounds.
ABDOMEN: Soft, obese, and +2 bowels sounds present without evidence of organomegaly, mass, rebound, or guarding. Negative for CVA tenderness.
EXTREMITIES: Intact without cyanosis or clubbing, but there was trace lower extremity edema. Peripheral pulses of lower extremities were diminished. There was a burn scar present on the right lower extremity.
NEUROLOGIC: Major motor function appeared to be intact. Detailed sensory exam of the lower extremities was not performed. Cognitive function appeared to be adequate; however, detailed exam was not performed. Ambulation and gait were not tested at this time.
PHYSICAL EXAMINATION: GENERAL: The patient is currently lying in bed, comfortable, in no apparent distress. He appears younger than his stated age. He answers all questions promptly and accurately. He is accompanied by his wife and he looks well nourished. HEENT: Head is normocephalic. Pupils are equal and reactive to light and accommodation. NECK: Supple. No JVD or lymphadenopathy is appreciated. CHEST: Symmetrical. Bilateral good air entry. HEART: Regular rate and rhythm. No murmurs, rubs or gallops appreciated. ABDOMEN: Flat, positive bowel sounds, slightly distended but not tender to palpation. No masses. No hernias or any other abnormalities noted. EXTREMITIES: 2+ pulses throughout. Full range of motion. No cyanosis or edema is appreciated. NEUROLOGIC: The patient is alert, awake and oriented with no neurological deficits appreciated.
PHYSICAL EXAMINATION: The examination reveals that the patient has fair features. Facial freckles are noted. Examination of the face reveals the patient has some volume loss and gravitational changes associated with aging. At the periocular area, a tear trough is noted with some protruding lower lid bags. The tear trough extends around the complete lower portion of the inferior orbital rim. The patient has some separation between the middle and medial fat pads in the cheek with a mild nasolabial fold. The patient’s perioral area has many signs of facial aging, including perioral lip line’s loss of lip volume and deep marionette creases with a jowl. The jowl does not completely disturb the mandibular line but rests against the labiomental fold. The patient has a longer lip on the left side than the right with a small asymmetry also in lip height. The patient’s seventh nerve is equal and symmetrical. She has a strong DAO.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 108/66, temperature 98.8, pulse 108, respirations 20, 100% on room air.
GENERAL: The patient is a (XX)-year-old who is awake, alert, pleasant, holding some ice on the left side of her face. She is in no obvious distress.
HEENT: She does have some soft tissue swelling around the left orbital rim and tenderness to palpation throughout this area, a little tenderness across the zygomatic arch on the left hand side, but there is no crepitation or instability noted. Her pupils are equal and reactive. Extraocular muscles are completely intact. There is no obvious injury to the eye itself. Her TMs show no hemotympanum. She also had some abrasions in her upper lip but nothing which would require any repair.
NECK: C-spine is nontender to palpation, axial loading and range of motion. She does have some minimal erythema to the left anterior neck.
HEART: Regular rate without murmur, rub or gallop.
LUNGS: Equal breath sounds bilaterally with no wheezing, rales or rhonchi. There is no chest wall tenderness or instability.
ABDOMEN: No external sign of injury. Bowel sounds are present. Abdomen is soft, nontender, no rebound, no guarding, no rigidity. There are no palpable masses. There is no flank pain on exam.
EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis and no edema.
SKIN: No rash.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed female with Down syndrome.
VITAL SIGNS: Temperature 98.6 degrees, pulse 102, respirations 18, and blood pressure 116/78.
HEENT: Examination of the head and neck still shows slight left facial weakness. Pupils are equal and reactive to light and accommodation.
NECK: Supple to palpation.
LUNGS: Diminished breath sounds.
HEART: Heart sounds S1 and S2 are present with regular rate and rhythm.
ABDOMEN: Normoactive bowel sounds. Soft and nontender. No organomegaly is palpated.
EXTREMITIES: Examination of the extremities shows normal tone in the right upper and lower extremities with decreased tone in the left upper and lower extremities. Peripheral pulses are intact. Homans sign is absent. The patient still has clonus in her left ankle but was able to demonstrate some active extension of her right. There is no significant tenderness on the left leg on palpation.
