Physical Assessment : Symptoms And Treatment

Abdomen: Obtuse with minimal bowel sounds, slightly distended. There is RLQ (right lower quadrant) tenderness with guarding and with pinpoint rebound. Positive McBurney and obturator signs with a negative psoas sign.

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.

No history of skin disease. Skin is pink, dry, and void of bruising, rashes, or lesions. No recent hair loss; head is normocephalic. Pupils equally reactive to light; no history of glaucoma or cataracts. Ears are in normal alignment; no history of chronic infections, hearing loss, tinnitus, or discharge. Nose and sinus history includes clear nasal discharge “since last October”, and occasional nose bleeds; states she use to get nose bleeds often as a child. Mouth and throat are absent of lesions; no bleeding gums, sore throat, dysphagia, hoarseness, or altered taste. Neck is void of pain, swelling,

Breasts: no masses, no nipple retraction, no discharge. Heart: S1 and S2, no gallops, rubs, or murmurs appreciated. Abdomen is scaphoid, soft and non-tender with positive bubble sounds. Pelvic/ Rectal: deferred as patient has recently visited her GYN for a routine Pap smear. Neurologic exam reveals normal motor strength in all muscle

BB’s skin presents as pink, warm and dry. No obvious signs or symptoms of abnormal bruising or lesions present however, the patient states that the skin has of late has

No scalp lesions. Dry eyes with conjunctival injection. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosions of the mucosa. She has a large ulceration of the mucosa at the bite margin on the left. She has some scattered ulcerations on her hard and soft palette. She has difficulty opening her mouth because of pain. Tonsils not enlarged. No visible exudate. SKIN: She has some mild ecchymosis on her skin and some erythema, she has some patches but no obvious skin breakdown. She had some fissuring in the buttocks crease. PULMONARY: Clear to precussion and auscultation, bilaterally. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Soft, non-tender, protuberant, no organomegaly, and positive bowel sounds. NORALOGIC EXAME: Cranial nerves ii – xii are grossly intact, diffuse hyporeflexia. MUSCULAR SKELETAL: Erosive destructive changes in elbows, wrist, and hands consistent with rheumatoid arthritis. Has had bilateral total knee replacements with stovepipe legs and perimalledal pitting edema 1+. I feel no pulse distally in either leg. PHYCIATRIC: Patient is a little anxious about these new symptoms and there significance. We discussed her situation and I offered her psychiatric services, she refused for now.

PHYSICAL EXAM: Temperature 98.6, Blood pressure 140/90. Pulse 110. Respirations 26. Her lungs are clear, showing mild signs of distress. Heart sounds are normal, irregular rhythm and bradycardia noted. No edema noted in extremities. Patient skin is cool to touch, slightly clammy. EEG shows prolonged QRS wave, with ischemic ST changes and PVCs. Chest radiograph clear.

On Exam:  BP today was 140/86. Head and neck exam was all clear. She had no oral or nasal ulcers. She had no lymphadenopathy or bruits. Heart sounds were normal and the chest seemed clear, as did the abdominal exam. Musculoskeletal exam disclosed widespread Heberden's and Bouchard's nodes. She had no swelling or stress pain at the MCPs. She was not tender at the CMC joints. She had no swelling in the wrist, elbows or shoulders. She had no soft tissue tender points. She has bilateral knee crepitus but only slight instability and no effusions. She had actually good range of movement of both hips. She was tender in the lumber spine and has a scar at the lower lumbar spine from her previous operations. Her feet are somewhat flat with tenderness across the

This is an unexpected finding for someone with adequate nutrition, and could be a sign of dehydration.

O: Left Pointer Finger Nail: A Blue colored discoloration, tender to palpation; Left pointer Finger distal phalanx 1 cm in length purple discoloration, small, pin tip size open area, bleeding has stopped. mild edema

Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 - S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2

O: Right index finger: bruising of finger, mild edema, Full Active and passive ROM, Tender to palpation, no warmth. Brisk capillary refills; right radial and ulnar pulse +3

No known allergies, no sinus, tenderness, no epistaxis, no bleeding gums, patient has partial dentures, one dental carrier noted, tongue is slightly coated, no swelling, lumps or tenderness noted in throat,

General Appearance: The patient is 36-year-old Caucasian woman who is in no apparent distress. Patient is alert and oriented to person, place, time and situation, cooperative, well-nourished, well-groomed, and dressed appropriately for the weather. Hygiene is excellent

Nose: Nares patent without any obstruction. No frontal or maxillary tenderness during palpation of the sinus cavities.