PHYSICAL EXAM:
GENERAL: The patient is an awake and alert, very socially engaging (XX)-month-old male who is accompanied to this visit by both of his parents. He spends most of the visit talking with himself, with his parents, and with the providers.
HEENT: No conjunctival injection. Oral mucosa is moist.
NECK: VP shunt palpable on the right neck.
CARDIOVASCULAR: Extremities equally warm.
RESPIRATORY: No increased work of breathing.
ABDOMEN: Soft, nondistended.
SKIN: No breakdown or rashes. There is some desquamation of the right thumb attributed to thumb sucking.
MUSCULOSKELETAL: Spine is clinically straight. He has full passive range of motion of the bilateral upper extremities. Lower extremities with hip flexion to 120 degrees. Galeazzi negative. Hip abduction with the knees flexed is 30 degrees bilaterally. Hip internal rotation is symmetric at 70 degrees bilaterally. Hip external rotation is symmetric at 45 degrees bilaterally. Popliteal angle is 50 degrees on the right and 60 degrees on the left. These are similar to previous measurements of 45 on the right and 60 on the left. Ankle dorsiflexion with the knee flexed is 10 past neutral after relaxation. This is the same as last visit. Ankle dorsiflexion with the knee extended is 5 degrees past neutral, which is more than last visit when it was 2 degrees past neutral.
NEUROLOGIC: He is awake and alert. Verbalizes throughout the entire visit saying phrases like “toy,” “bye-bye,” and his own name. From a motor standpoint, he reaches out with both upper extremities. He transfers from the right to the left and the left to the right. Reaches both upper extremities overhead. He has good head and trunk control. He is able to sit unsupported when placed in that position on the exam table with his hips and knees flexed. He has increased tone of his bilateral lower extremities with a modified Ashworth 2/4 at his hip adductors and knee flexors and 3/4 at his ankle plantarflexors. Tone is mildly worse than at his previous exam when he was 1+ at his hip adductors, 2 at the knee flexors, and 2 to 3/4 in the ankle plantarflexors. No clonus was appreciated. He is hyperreflexic, 3/4, at the bilateral patella.
PHYSICAL EXAM: MSE: The patient presents as usual with ponytail pulled back behind her head to the mid level of her back, dark and large-framed glasses, minimal amount of make-up, quiet, not always talkative, but when she talks, her speech is goal directed without evidence of thought disorder. Good syntax and grammar. Sensorium and cognition grossly intact. Insight and judgment are partial and decreased in regard to her continuing to do things that cause her negative consequences with the legal system. No abnormal involuntary muscle movements, tics or mannerisms are noted. The patient states she is not currently hearing any voices or having any thoughts of wanting to hurt herself or others. Insight and judgment are still somewhat decreased and only partial.
PHYSICAL EXAM:
VITAL SIGNS: Normal. The patient states pain 5/10.
GENERAL: A very nice elderly woman who is very thin.
MUSCULOSKELETAL: Fair muscle tone with very thin muscles.
BACK: Examination of the back shows no midline tenderness. There is obviously some mild kyphosis. She is tender in the upper gluteal area on the left but not over the sciatic notch. She has negative straight leg raising, but it is very painful for her to move about as she does have some muscle spasm in the lumbar paraspinal, on the left. Distally, she has normal sensory down the leg, and her circulation is good with normal capillary refill.
ABDOMEN: Benign. No organomegaly or mass. No pulsatile masses or bruits.
LUNGS: Revealed rather distant sounds. No rales.
HEART: Distant heart tones. No murmur.
PHYSICAL EXAM:
VITAL SIGNS: Weight 210 pounds. Height 5 feet and 4 inches. BP 122/90 left arm, 126/90 right arm; pulse 76 and regular; respirations 18 and unlabored.
HEENT: Normocephalic, atraumatic. PERRL, EOMI, no lid lag, no exophthalmos, no xanthelasma, conjunctivae pink, no scleral icterus. Ears and nose externally normal. Pharynx normal.
NECK: No JVD. No carotid bruit, no thyromegaly, no adenopathy. Surgical scar present in the neck.
CHEST: Lungs clear. Breath sounds normal bilaterally.
HEART: PMI in the 5th intercostal space, no lift or thrill. S1 and S2 normal. No gallop, murmur or rub.
ABDOMEN: Flat, soft, nontender. Normal bowel sounds. No bruit. No palpable aortic aneurysm, mass or organomegaly. Moderately obese.
EXTREMITIES: Full range of motion. No cyanosis, clubbing, or edema.
MUSCULOSKELETAL: No gross joint deformity or swelling.
NEURO: Alert and oriented x 3. Cranial nerves intact. Balance, gait and coordination normal. Normal affect.
SKIN: No significant skin lesions or rashes.
PSYCHIATRIC: Mentation normal.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6 orally, pulse 94, respirations 18, blood pressure 96/64, O2 sat 98% on room air.
GENERAL: She is sitting on the examination table in no acute distress. She is alert and interactive and answers questions appropriately. She does not appear to be in any discomfort.
HEENT: Pupils are equal, round, and reactive to light. Sclerae are white. Conjunctivae are pink. Extraocular eye movements are intact and nonpainful. Mucous membranes are moist and pink.
NECK: Supple without jugular venous distention or lymphadenopathy.
LUNGS: Lungs are clear to auscultation bilaterally. There are no wheezes, rales or rhonchi, and she has good air entry throughout.
HEART: Regular rate and rhythm with normal S1 and S2. There were no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended. There is no rebound or guarding.
MUSCULOSKELETAL: Full range of motion in all joints. There are no peripheral extremity clubbing, cyanosis or edema.
SKIN: No rashes and is warm and dry with capillary refill time of 2 seconds.
NEUROLOGIC: Alert and oriented x 3. She has a normal strength, gait, and balance.
BREASTS: Reveals a left breast that has a palpable nodule and cord in the left upper outer quadrant at approximately 3 o’clock consistent with unexpressed milk. The remainder of the breast is soft. In the left upper outer quadrant, there is overlying erythema and tenderness to palpation. There is no fluctuance indicative of abscess. There is no bloody discharge expressible from her nipple. The overlying erythema is also warm to the touch but not indurated.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 124/78, pulse 110, respirations 20, temperature 96, O2 saturation is 100% on room air.
GENERAL: Well-developed, well-nourished Caucasian male in no acute distress.
HEENT: Sclerae are slightly icteric. Extraocular motions intact. Pupils are equal, round and reactive to light. Mucous membranes are moist. Oropharynx is clear.
NECK: Supple without lymphadenopathy or JVD.
RESPIRATORY: Breath sounds are clear and equal. No rales, rhonchi or wheezes.
CARDIOVASCULAR: Tachycardic, regular rhythm with good distant pulses.
ABDOMEN: Soft, distended with mild caput medusae and an easily reducible umbilical hernia.
EXTREMITIES: He has 5/5 strength throughout.
SKIN: Warm and dry.
NEUROLOGIC: Awake, alert and oriented. No focal deficits.
PSYCHIATRIC: Affect is appropriate.
PHYSICAL EXAMINATION: On admission, the infant was vigorous, pink, and well appearing. Anterior fontanelle was open and flat. Normocephalic and atraumatic. Positive red reflex in the eyes. Ears were normally set. No cleft lip. No cleft palate. There were no masses in the neck. The chest was symmetrical and clear to auscultation bilaterally. There were no murmurs, rubs or gallop in the heart. Abdomen was soft, nontender, nondistended. No masses and normal female genitalia with no hip clicks. On the back, there were no hair tufts or dimples.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 134/58, pulse 76, respirations 16, temperature 97.8.
GENERAL: Well-nourished, well-developed male in no acute distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round and reactive to light.
NECK: Full range of motion with no meningeal signs.
ABDOMEN: Soft, nontender. No masses or organomegaly.
EXTREMITIES: Examination of his left knee shows that there is no joint swelling. The patella is medial and nonballotable. He does have some tenderness with patella ballottement. There is no femoral tendon pain and the patella does track medially. No tenderness medially or laterally. No tenderness posteriorly. No posterior fossa mass. Ligamentous testing shows instability with anterior and posterior drawer as well as varus and valgus stress testing; it is stable. The grind test is that there is no pain with axial loading. There is no erythema or edema noted here. The patient was observed ambulating without difficulty here in the emergency department. Remainder of extremity exam is atraumatic without any joint pain, redness or swelling.
SKIN: Warm and dry. No noted skin rashes or lesions.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/86, pulse 78, respirations 20, temperature 97.8, O2 saturation of 96% on room air.
GENERAL: The patient is an obese male who does not appear in any acute distress and is alert and oriented x3.
HEENT: Pupils are equal, round and reactive to light and accommodation. Extraocular movements are intact. The patient has moist mucous membranes.
NECK: Supple with no lymphadenopathy and full range of motion. The patient does note pain in his right shoulder when he turns his head to the left.
LUNGS: The patient’s lungs are clear to auscultation bilaterally with no wheezes, rales or rhonchi appreciated.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops appreciated.
ABDOMEN: Obese, soft, nontender with positive bowel sounds.
NEUROLOGIC: Cranial nerves II-XII are grossly intact. The patient has 5/5 strength throughout, including his right upper extremity. The patient has normal sensation.
MUSCULOSKELETAL: The patient has tenderness to palpation in multiple areas in his right shoulder area, both medially and laterally. The patient notes pain to even the lightest of palpation. The patient also notes pain with movement of his right shoulder, particularly abduction and movement posteriorly. The patient notes radiation of this pain to his right neck. The patient’s extremities are warm with no clubbing, cyanosis or edema and 2+ pulses is all four extremities.
PHYSICAL EXAM:
GENERAL: Well-developed, well-nourished black female in no acute distress.
VITAL SIGNS: T 98.6, R 18, P 64, BP 158/82, pulse ox on room air is 92%.
HEENT: EOMI. Conjunctivae are clear. Oropharynx is clear. Mucous membranes are moist.
NECK: Supple. No JVD or asymmetry.
HEART: Regular rate and rhythm, 2+ distal pulses.
LUNGS: Clear to auscultation and equal bilaterally without any retraction or crackle.
ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No mass, rebound, rigidity or guarding.
EXTREMITIES: Negative cyanosis, clubbing or edema.
SKIN: Warm and dry. No rash or nodules noted.
PSYCHIATRY: Appropriate mood, affect and judgment.
NEUROLOGIC: GCS 15. Cranial nerves II through XII are intact. Motor 5+/5+, equal bilaterally including deltoids, biceps, triceps, wrist extensors, wrist flexors, interossei, thumb extensors and thumb opposition. Normal finger-to-nose. Normal range of motion. 2+ pulses x4. Brisk capillary refill x4. With Phalen’s, there is no reproducible symptoms but Tinel’s causes slight worsening of the tingling in her left fourth digit, but she states that she has had carpal tunnel before and this feels different. We are unable to reproduce her symptoms when pushing on her ulnar groove; although, she states that she does lean on her left elbow quite a bit and has been laying in bed quite a bit, laying on her left elbow watching TV. Her toes are well perfused. There is no rash or trauma. No signs of any circulatory compromise or infection.
PHYSICAL EXAMINATION: General: This thinly built, middle-aged Hispanic male is alert, in no acute distress. Vital Signs: Blood pressure 122/72, pulse 80, respirations 18, and temperature 98.2. HEENT: Head normocephalic. Pupils are reactive. Fundi not visualized. Throat is clear. Ears and Nose: No inflammation. Nasal mucosa injected. Neck: No lymphadenopathy. Trachea midline. No bruits. Chest: Reveals equal movements with decreased excursions. Percussion note resonant throughout. Occasional wheezes are scattered bilaterally. No crackles on either side. Expirations are prolonged. Heart: Heart sounds are regular. S1 and S2 heard. No S3, gallop or murmur. Abdomen: Soft, protuberant without mass. No organomegaly. The bowel sounds are active. Extremities: Varicosities. No edema. Reflexes are brisk. There are no gross motor deficits. Neurologic: Cranial nerves grossly intact. Rectal: Exam is deferred. Skin: No lesions are observed.
PHYSICAL EXAMINATION: GENERAL: This averagely built, middle-aged Hispanic female is alert, in no acute distress. Mild pallor. No cyanosis or icterus. No lymphadenopathy or peripheral edema. Skin turgor was good. VITAL SIGNS: Blood pressure is 112/62, pulse 94, respirations 24, and temperature 98. HEENT: Head normocephalic. Pupils are reactive. Nasal mucosa edematous. Throat is mildly injected. Ears, mild cerumen. Fundi are not visualized. Neck: Supple. No lymphadenopathy. Trachea midline. No bruits or thyroid enlargement. Chest: Reveals equal movements with a scar of surgery in the left breast area with a draining wound in the nipple area. No axillary lymphadenopathy. Chest also revealed decreased breath sounds at the bases with occasional wheezes in the upper lung fields. No definite crackles. Heart: The heart sounds are regular. S1 and S2. Heard no murmur. Abdomen: Soft, protuberant. Scars of surgery are noted. No organomegaly or tenderness. Bowel sounds active. Extremities: No edema. Mild varicosities. No calf tenderness. Homans sign is negative. Reflexes are brisk. There are no gross motor deficits. Neurologic: Cranial nerves grossly intact. Rectal: Exam is deferred.
PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished white male in no acute distress. VITAL SIGNS: T 98, R 18, P 84, blood pressure 168/128. Without any intervention, supine pressure was 148/96, pulse of 84, standing 155/104, pulse of 90. Repeat blood pressure upon resting here 130/94. HEENT: EOMI. Conjunctivae are clear. Oropharynx is clear. Mucous membranes are moist. NECK: Supple. No JVD or asymmetry. Funduscopic exam shows sharp disks. No nicking or hemorrhages. He did have a nosebleed from the left naris recently, but his nares are bilaterally clear without any signs of active bleeding or other abnormality. HEART: Regular rate and rhythm. 2+ distal pulses. LUNGS: Clear to auscultation and equal bilaterally without any retraction or crackle. ABDOMEN: Positive bowel sounds. Soft, nontender, nondistended. No mass, rebound, rigidity or guarding. EXTREMITIES: Negative cyanosis, clubbing or edema. SKIN: Warm and dry. No rash or nodules noted. PSYCHIATRY: Appropriate mood, affect and judgment. NEUROLOGIC: Awake and alert, oriented. Cranial nerves II through XII grossly intact. Moves all four extremities. Glasgow coma scale 15. Motor 5+/5+ equal bilaterally. Negative drift. Light touch intact. Normal finger-to-nose. No Kernig or Brudzinski. Dix-Hallpike maneuver caused him to feel “nauseous” but not necessarily dizzy.
PHYSICAL EXAM: GENERAL: Examination revealed a white male who is awake and alert. VITAL SIGNS: Temperature 97.2, pulse 78, respirations 18, blood pressure 146/86. HEENT: Pupils are equal and reactive. Conjunctivae are clear. There is some mild to moderate edema, swelling of the right facial maxillary region with tenderness. No significant erythema, warmth. Oropharynx examination revealed poor dental hygiene with sensitivity in the right upper canine and right premolar area. No gingival drainage. No trismus. Airway is intact. No stridor. NECK: Supple, no meningismus. HEART: Regular rate and rhythm. LUNGS: Sounds clear. EXTREMITIES: Show no joint swelling. Full range of motion actively. NEUROLOGIC: The patient is awake, alert and oriented x3, no focal deficit.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 158/84, temperature 96.8, pulse 96, respirations 20. Pulse ox is 97% on room air.
GENERAL: This is a (XX)-year-old white male who appears to be in some discomfort though is alert and oriented x3.
HEENT: Head is normocephalic, atraumatic.
NECK: Supple though he is slightly tender to palpation throughout the posterior aspect of the neck.
CARDIAC: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
BACK: The patient is tender to palpation in the thoracic midline and paraspinal muscles bilaterally. No other back tenderness throughout.
EXTREMITIES: The patient ambulates without difficulty. Reflexes are +2 bilaterally. Strength is 5/5 bilaterally. Distal pulses palpable. Sensation is intact throughout.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 118/74, pulse 74, respiratory rate 18, temperature 97.2.
GENERAL: This is a well-appearing, African-American gentleman in no acute distress.
HEENT: The pupils are equal, round and reactive to light. The extraocular muscles are intact. TMs are clear bilaterally. No erythema or effusion. Nares are patent bilaterally. The oral mucosa is pink and moist. No oral lesions. No posterior pharynx erythema or exudate. Uvula is midline. No swelling or asymmetry. He has some mild frontal sinus and maxillary sinus tenderness to palpation bilaterally. He does have obvious rhinorrhea with some swelling of his turbinates. There is no obvious colored mucus in his nasal passages.
NECK: Supple, without lymphadenopathy or JVD.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds. No organomegaly. No masses palpated.
MUSCULOSKELETAL: The patient moves all four extremities in all directions. No cyanosis, no clubbing, no edema.
SKIN: Warm and dry, without any rashes or lesions.
NEUROLOGIC: The patient is awake, alert and oriented x3. Cranial nerves II through XII are checked and intact. The motor is 5/5 in the bilateral upper and lower extremities. Sensation is grossly intact to light touch. Reflexes – biceps, triceps, patellar and Achilles tendons are 2+.
PSYCHIATRIC: The patient had normal affect, normal insight, normal judgment.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 128/88, pulse 58, respirations 16, temperature 96.8, satting 98% on room air.
GENERAL: The patient is a well-appearing female in no acute pain or distress. HEENT: Atraumatic, normocephalic. Extraocular movements are intact. There is no pallor or icterus. Mucous membranes are moist.
NECK: Supple. There is no JVD.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmur, gallop or rub.
ABDOMEN: Soft, nontender, nondistended.
PELVIC: Normal external genitalia. The patient has some white discharge on exam, but there is an amount of blood in the vault making the exam somewhat difficult. No cervicitis is noted. No cervical motion tenderness, fundal tenderness or adnexal tenderness.
EXTREMITIES: No clubbing, cyanosis or edema x4.
NEUROLOGIC: Grossly intact.
PSYCHIATRIC: Affect is appropriate.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 124/74. Pulse 68. Respirations 20. Temperature 98.8. Pulse ox is 99% on room air. GENERAL: The patient is alert and oriented x3 and in no apparent distress. HEENT: Normocephalic, atraumatic. Extraocular muscles are intact. Pupils are equal, round and reactive bilaterally. Mucous membranes are moist. NECK: Supple. No C, T or L-spine tenderness. HEART: Regular rate and rhythm with no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. CHEST: The chest has no tenderness to palpation over the rib cage. ABDOMEN: Soft and nontender. Bowel sounds are present. No rebound or guarding. No peritoneal signs. EXTREMITIES: Without clubbing, cyanosis or edema. The patient has 2+ pulses in all distal extremities. NEUROLOGIC: Intact and nonfocal. Gait is normal. Strength is 5/5 in all extremities. Sensation is intact. No dysdiadochokinesia or dysmetria. Cranial nerves II through XII are intact.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 142/100, pulse 68, respirations 18, temperature 97.8, O2 sat 96% on room air.
GENERAL: This is a well-developed, well-nourished, pleasant (XX)-year-old Caucasian male in no apparent distress. He is awake, alert and oriented x4. He is appropriate throughout the exam.
HEENT: Pupils are equal, round and reactive to light. Extraocular motions are intact. Sclerae white. Conjunctivae are pink. TMs clear bilaterally. Oral mucosa is moist and pink with no visible lesions.
NECK: Supple. No lymphadenopathy, no JVD, no carotid bruit.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES: Without cyanosis, clubbing, edema. Pulses 3/4 throughout.
NEUROLOGIC: Cranial nerves II-XII grossly intact. Strength is 5/5 throughout. Sensation is intact and symmetric. Gait is normal. Romberg is negative. Cerebellar function tests are appropriate and symmetric. He is able to ambulate on his toes. He is able to ambulate on his heels. He has no saddle anesthesia. Straight leg raise reproduces his pain on the right side. Straight leg raise on his left leg does not reproduce the pain.
