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
PHYSICAL EXAMINATION: Vital Signs. TEMPERATURE: 101.0, Blood Pressure- 127/179, Heart Rate-129, Respirations- 185, Weight-215. Situations 96% on room air. Pain Scale- 8/10. HEENT-Normal cephalic, atrumatic pupils equally round and reactive to light. Extra ocular motions intact. ORAL: Shows oral pharynx clear but slightly dry mucosal membranes. TMS: Clear. NECK: Supple, No thrangegally or JVD. No cervical, subclavicular, axilarry or lingual lymphinalpathy.
During Dr. Wallace’s clinic, one of the golf girls came into the Athletic Training Room complaining of right shoulder pain. Dr.Wallace first began the evaluation by asking if she remembered how she hurt her shoulder. The golfer said she had been at home during winter break and was wearing socks in the house. She said she was running and fell and when she was falling, she attempted to catch herself by using a nearby wall. Dr. Wallace then checked her strength by asking her to abduct her shoulders as far as she could. He then added resistance and noticed weakness in her right shoulder. He tested the ligaments and told her they were all intact. He also asked her if she had been experiencing any numbness, tingling, etc. since she fell and she
In the emergency room, Rudd was connected to the cardiac monitor, labs were drawn and a 20-guage peripheral IV was started in the right arm. An IV infusion of nitroprusside was started and vital signs were recorded periodically. The Pain was assessed using a PQRST pain assessment method and Rudd rates throbbing pain bilaterally in the head with a pain score of 8 that aggravates with moving and does not radiate to elsewhere other than the head. The orthostatic BP shows no changes. The E.D physician decides to admit Rudd in CCU to further monitor his blood pressure and watch for any signs of organ damage. The E.D physician writes an order for pain management and transfer to CCU. The ER nurse
Client mention she have an appointment scheduled at Woodhull Hospital to see the neurologist on 10/2015.
Per medical report dated 11/24/15 by Dr. Cano, the patient is complaining of severe numbness in the right hand, tightness around the right worse than left hand. She also associates this with dropping items. She is unable to button her shirts or raise her arms up to her elbows. This is continuous all day long. Also, associated is severe low back pain with numbness, radiation, and muscle spasm in the thoracic area, and numbness and radiation down the right sciatic nerve with severe low back pain. She continued to work, sixteen-hour shifts, seven days a week. At this time, she is unable to function. She states that she has had 24 sessions of physical therapy that has definitely helped her.
Patient is an 86-year-old right-handed white female who is a poor historian. She states she saw me several years ago, but cannot recall for what. She did see Geoffrey Starr, MD in 2011 for episodes of numbness and tingling in the right side of her cheek. He did a workup, which included the EEG, EMG, and carotid studies. She was complaining of some right upper extremity and left lower extremity numbness and tingling as well. These were all negative. Her PCP switched her from aspirin 81 mg to Plavix 75 mg. Dr. Starr added Trental to that. The patient states that over the years, she continued to have the numbness and tingling episodes of the right side of her face. The last several seconds at times, rarely
“Patient is currently having blurred vision, facial pain, numbness in both upper and lower extremities,
Cardiovascular. Client denies chest pain, palpitations, murmurs, any arrhythmias, hypertension, awakening at night with shortness of breath, or dizzy spells. Client has not had an electrocardiogram.
Patient is a 34-year-old left-handed white male who states that in January he was in a parking lot and was hit by a plow truck that was backing up. His back was turned and he did not know what was happening. He fell on his back and hit the back of his head on the tailgate. He denied any loss of consciousness. He did have a significant headache and neck pain, but no neurological symptoms. He did have some pain in his right hand and right ankle after this. He did present to the emergency room, where an unenhanced CAT scan was negative. Since then however, he has been having daily headaches. He has an almost constant, dull, mild bitemporal pressure sensation, but he also has significant
On Primary Treating Physician’s Progress Report (PR-2) dated 08/11/2017, the patient presented with unchanged symptoms. His left-hand pain was rated at 8/10. and was described as constant and sharp. The pain was aggravated with certain movements and gripping. The
Patient denies any straining or discomfort on defecation. Patient denies having any recent change of bowel movements as, constipation, diarrhea, black stools, or rectal bleeding. She denies hemorrhoids, or fistula. Patient also denies using laxatives or antacids.
Cardiac: rRegular rate and rhythm, no murmurs, rubs, or gallops; no JVD, thrills, or heaves; PMI non-displaced at 5th intercostal space
Ms. bogart is a 50-year old healthy women with a work history as a typist, who presents with a chief complaint of tingling in her left hand’s fingers (thumb and 2 adjacent) over the last 25 hours. The patient’s symptoms began last night while watching television with her arm in a “funny position”. She than shook it out to cease the pain temporally, however it reoccurred. This morning when waking up and driving to the clinic (2 hours away) she describe her pain as worsening. There is no radiation, thus the pain is localized to her three fingers. She appears to have no swelling, redness, or immobility, as well as no fever.
Cardiac: Regular rhythm without murmur, normal S1and S2. One plus edema to bilateral lower extremities. Capillary refills are presents and carotid bruits are absent.