Bleeding gums; dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarseLast dental exam this yearNeckLumps; swollen glands; goiter; pain; neck stiffnessNegativeBreastsLumps; pain; discomfort; nipple dischargeNegativePulmonaryCough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic painsNegativeCardiacChest pain or discomfort; palpitations; dyspnea; orthopnea; PND; edemaNegativeG/IAppetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; Negative3
hematochezia; melena; hemorrhoids; constipation; diarrhea; food intoleranceUrinaryFrequency; nocturia; urgency; dysuria;hematuria; incontinenceMALES: caliber of urinary stream; hesitancy; dribblingNegativeG/U (General)Sexual habits; interest; function; satisfaction; use of birth control methods; HIV exposureNot sexually activeMale G/UDischarge from or sores on penis; testicular pain/massesN/AFemale G/UMenarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMPVaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding; Depo Provera for painful menses since age of 16. Menses- spotting off and on and light about 2 weeks before shot is due.PeripheralVascularClaudication; leg cramps; varicose veins; hx of blood clotsNo history- Factor V LeidenMusculo-skeletalMuscle or joint pain; joint stiffnessNavigate NeuroSyncope; seizures; weakness; paralysis; numbness/tingling; tremors;involuntary movementsNegativeHemeHx of anemia; easy bruising or bleeding; blood transfusionsNegativeEndoHeat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe sizeNegativePsychNervousness/anxiety; depression; memory changes; suicide attemptsNegativeGeneral Findings and Physical ExamGeneral ObservationsDoes patient appear to be their stated age?Appear appropriate for ageLevel of consciousnessAlert and oriented x 3Skin colorPink, dry, moist. No rashes or lesionsNutritional statusWell-nourishedPosture and positionAppropriate posture and positionObvious physical deformitiesNoneMobility: gait, use of assistive devices, ROM No issues4
of joints, no involuntarymovementFacial expressionAble to smile, face symmetricalMood and affectAppears happySpeech: articulation, pattern, content and appropriate, native languageFluent speech. Articulation appropriate. English speaking.HearingNo issuePersonal hygieneClean appearing, no foul odorsMeasurements and Vital SignsWeight184 poundsHeight5 feet 6 inchesBMI29.7Radial pulse: raterhythm64RegularRespirations: ratedepth16regularBlood pressure (indicate if sitting or lying)118/62Temperature (if indicated)98.9 oralPain assessmentDenies pain -0/10SkinHands and nailsNo ridges, clubbing or thicknessColor and pigmentationAppropriate for ethnicityTemperatureWarmMoisturemoistTexturesmoothTurgorelasticPresence of lesions?noneHead and FaceScalpHairCraniumNo dandruffThick and shinyRound, no lesions, lumps or tendernessFace (cranial nerve VII)Intact and symmetricalTemporal artery and temporomandibular jointCondylar movement easily felt.
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- Spring '16
- Shelley Ashby
- pulse, factor V Leiden