History And Physical. M. J., 46 Y.O. Black Female Arrived

1025 WordsApr 7, 20175 Pages
HISTORY AND PHYSICAL M. J., 46 y.o. black female arrived at emergency department via ambulance with complaint of left upper extremity weakness and headache. She is awake, alert and in no acute distress and is a reliable historian. SUBJECTIVE Chief complaint: “I have a bad headache and I could not move my left arm but it’s getting better.” History of present illness: Patient was at work and developed sudden onset numbness and weakness in the left arm and headache pain described as “dull and throbbing.” Pain is 8/10 on pain scale. She denies nausea and vomiting. Patient reports she has occasional headaches, which she treat with Tylenol or Motrin, but this is the first time she experienced numbness…show more content…
Patient reports occasional headaches. She denies head trauma. Eyes: PERRLA, pupils 3 mm, last eye exam 2 years ago. Ears: Hearing intact, ear canals patent, no drainage Nose: Nostrils patent, no drainage, sinuses clear. Mouth/Throat: Oral mucosa pink and moist, positive swallow and gag reflex. Neck: Neck symmetrical, active range of motion, no masses. Breasts: Breasts symmetrical, no masses, no dimpling. Patient reports BSE performed monthly. Lymph Nodes: Lymph nodes nonpalpable, nontender. Respiratory: Lungs clear to auscultation, on room air. Infrequent, nonproductive cough. Cardiac: Regular heart rate and rhythm, +2 radial pulses, +2 pedal pulses, + capillary refill < 3 sec, no edema. Gastrointestinal: Abdomen soft, non-tender, + bowel sounds in all quadrants, regular diet, last bowel movement prior to admission. Genitourinary: Patient voids without difficulty and reports regular menses. LMP 2 weeks ago. Musculoskeletal: Moves all extremeties, LUE slighly weaker than RUE Neurologic: Patient is alert and oriented x 4. She is calm and cooperative. Speech is clear and spontaneous. No facial droop, tongue midline. Numbness in LUE has resolved since admission. Laboratory and diagnostic examinations: EKG Echocardiogram CT Head CTA Neck CBC Chem 10 ASSESSMENT • Headache and left arm numbness/weakness Abnormal data: electrolyte imbalance, elevated BP, CTA shows 50% stenosis right carotid artery. • Elevated BP Abnormal

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