No renal artery bruits auscultated Negative McBurneys point GenitalRectal Exam

No renal artery bruits auscultated negative mcburneys

This preview shows page 4 - 6 out of 6 pages.

No renal artery bruits auscultated. Negative McBurney’s point. Genital/Rectal: Exam reveals uncircumcised male. No lesions or redness noted. Rectal exam had intact tone. Firm, symmetric, nontender prostate without nodules Musculoskeletal: Spine vertically aligned. Normal S-curvature. No nodules, masses or tenderness with palpation. Full ROM all joints. BUE and BLE symmetrical. No pain or tenderness palpated with joints. Extremities symmetrical in length, circumference, alignment and position. Muscle size symmetrical without atrophy or hypertrophy. No pain or tenderness with passive ROM. Active and passive ROM equal between contralateral joints. No crepitations or tenderness with movement noted. Thoracic and lumbar spine convex. Knees and feet are in proper alignment. Cervical spine concave with head erect in appropriate position. Skin folds symmetrical bilaterally. Feet in alignment with tibias. Toes are straight, forward and flat. No heat, redness, swelling or tenderness noted. Negative straight leg raise. Neurological: CN II-XII intact. DTRs 2+. Awake and alert, attentive. Oriented in all spheres. Speech fluent in English, and repetition intact. Able to point way out of room. Thoughts are appropriate. No evidence of disordered thinking. Monofilament intact. Vibratory sense intact to toes bilaterally. Motor strength 5/5. Proprioception of toes intact. Babinksi reflex negative. Intact finger to nose bilaterally. Intact rapid alternating movements. Stands and walks 8 feet without pain or tenderness. Slight swaying with Romberg test, but able to keep balance. No pain or tenderness with tandem walk, heel walk, or toe walk. Negative Brudzinski and Kernig sign. Skin: + dryness. No skin or nail lesions. Color uniform throughout. Skin turgor good. No edema, excessive sweating, or body odor noted. Nail beds are pink and intact. Edges smooth and round. No clubbing or cyanosis noted. LABS/DIAGNOSTIC EXAMS: CBC with differential: to detect major blood dyscrasias, and hypoxia Blood Cultures: check if patient has a fever, headache, nuchal rigidity or altered mental status CT: used to detect intracranial disease and should be done in new onset severe headache or headache associated with abnormal neuro signs MRI: 1 st choice for brain abscess Lumbar Puncture: measures CSF pressure; perform is CNS infection is suspected ESR (erythrocyte sedimentation rate): increased in presence of inflammation; perform if temporal arteritis is suspected Skull Radiograph: useful in posttraumatic headache
Image of page 4
ASSESSMENT: BB is a 20-year-old Caucasian male who presents with intermittent headaches that are becoming more frequent. His exam is positive for having tightness bilaterally on his shoulders and stiffness in neck with onset of headache. The pain diffuses all over his head with the most intense pain above eyes, through nose, cheekbones and jaw. He describes the pain as sharp, and gradually becoming more frequent. He claims to be stressed from college classes.
Image of page 5
Image of page 6

You've reached the end of your free preview.

Want to read all 6 pages?

  • Summer '15
  • Headaches, Headache, Denies eye pain, hernias. Denies penile, Denies eye trauma, Denies sickle-cell anemia

What students are saying

  • Left Quote Icon

    As a current student on this bumpy collegiate pathway, I stumbled upon Course Hero, where I can find study resources for nearly all my courses, get online help from tutors 24/7, and even share my old projects, papers, and lecture notes with other students.

    Student Picture

    Kiran Temple University Fox School of Business ‘17, Course Hero Intern

  • Left Quote Icon

    I cannot even describe how much Course Hero helped me this summer. It’s truly become something I can always rely on and help me. In the end, I was not only able to survive summer classes, but I was able to thrive thanks to Course Hero.

    Student Picture

    Dana University of Pennsylvania ‘17, Course Hero Intern

  • Left Quote Icon

    The ability to access any university’s resources through Course Hero proved invaluable in my case. I was behind on Tulane coursework and actually used UCLA’s materials to help me move forward and get everything together on time.

    Student Picture

    Jill Tulane University ‘16, Course Hero Intern

Stuck? We have tutors online 24/7 who can help you get unstuck.
A+ icon
Ask Expert Tutors You can ask You can ask You can ask (will expire )
Answers in as fast as 15 minutes