Snellen Case Studies

Normocephalic atraumatic. Pupils equally round and reactive to light, extraocular motions intact. Oral cavity shows oropharynx clear but slightly dried mucosal membranes. TM (tympanic membranes) clear. Neck, supple. There is no thyromegaly, no JVD. No cervical supraclavicular, axillary, or inguinal lymphadenopathy.

examination was remarkable for crackles at her right lung base. The examination of her cardiac,

Peripheral pulses posterior tibial and dorsalis pedis 2+ bilaterally. No edema on legs. Apical pulse regular rate and rhythm; s1, s2 noted. No murmurs, rubs or gallop rhythms. Denies dizziness, and fainting. Resp RR between 36-40 SpO2 85% per oximetry on 2 liters oxygen by n/c. Difficulty breathing and complaints of chest tightness. Patient unable to lay flat. Lung sound bilateral wheezes and crackles in right lower lobe. All other lobes clear A&P. Cough with yellow sputum. Tachypnea. Head of bed 45 degree. GI Last bowel movement 2 days ago, hard, long brown stool. Complains of constipation related to medication. Bowel sound are WNL in all 4 quadrants. Abdomen is soft, with no palpable masses. Poor appetite. Like sweet foods. Does not like vegetable or fruits. Like sodas, beer, scotch. Little water intake. GU Urinates every 2-3 hours. Yellow. No odor of urine. No history of UTI. One vaginal infection 2 years ago. No abnormal periods, last menstrual period 3 weeks ago. No pain or discharge. Skin Hair poorly groomed, dirty and oily. Nail are dirty and appear to be bitten. Skin clammy and moist with flushed color. IV IV of D5W at 125 mL in left forearm with 18

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,

Visual fields full to confrontation. Extraocular muscles intact. Pupils are slightly enlarged on the left compared to the right, which she states is old since her eye injury. They do respond directly and consensually. Normal facial symmetry, sensation, and movement. Tongue and uvula are midline. Normal shoulder shrug. Normal auditory acuity.

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.

L.H. report no concurrent or severe headaches; There was no head trauma, syncope or vertigo. Patient wears corrective lens with no difficulty of vision or diplopia; absent of inflammation, discharge or lesion. Last eye exam was in September of 2016 with no history of glaucoma, cataracts. L.H. denies having any frequent colds, sinusitis, epistaxis and trauma. Patient reports having obstruction stating, “it happens when I am lying down” with an occasional postnasal drip.

Visual fields full to confrontation. Extraocular muscles intact. PERRLADC. Normal facial symmetry, sensation and movement. Tongue and uvula were midline. Normal auditory acuity. Shoulder shrug is normal.

Eyes, ears, mouth: Patient denies difficulty with vision or double vision. Denies any eye pain, inflammation, discharge, denies history of glaucoma or cataracts, denies hearing loss or trouble hearing, denies sore throat, dry mouth, bleeding gums. Reports regular dental visits.

External ears, nose, and mouth appear normal in appearance, with moist mucous membranes. Neck is supple with trachea in midline. There is no cervical adenopathy noted.

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

Nose: Nasal mucosa moist, no tenderness or swelling noted, turbinate intact, no nasal drainage or discharge noted.

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,

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