Dysuria suprapubic pain frequency dribbling

Info icon This preview shows pages 2–5. Sign up to view the full content.

View Full Document Right Arrow Icon
(-) dysuria, (-) suprapubic pain, (-) frequency, (-) dribbling, (-) incontinence, (-) hematuria, (-) polyuria, (-) oliguria, (-) discharge Musculo-skeletal: (-) muscle pain, (-) joint pain, (-) swelling, (-) bone deformity, (-) weakness, (-) atrophy, (-) restriction motion Neurologic: (-) syncope, (-) seizure, (-) weakness/paralysis, (-) headache, (-) tremors (-) loss of memory, (-) dizziness
Image of page 2

Info icon This preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
Endocrine : (-) weight change, (-) goiter, (-) heat/cold intolerance, (-) polyuria, (-) polyphagia, (-) polydipsia, (-) abdominal growth Hematologic : (-) easy bruisability, (-) easy fatigability, (-) pallor PHYSICAL EXAMINATION General Survey The patient is lying on bed, alert, conscious and coherent, appears calm and is cooperative. no slurring of speech but with horseness. he is well nourished, with medium built body, well groomed and properly dressed. No gross deformities noted, non-ambulatory and requires some assistance to sit and stand. he is febrile and not in cardiorespiratory distress. Vital signs: BP = 150/90mmHg, PR = 96 bpm, RR = 20cpm, Temperature = 37.9 °C, SKIN The skin is brown, thick, smooth, moist with good skin turgor and mobility. No presence of abnormal pigmentations, ecchymoses, rashes and edema noted. Upper and lower extremities and trunk are warm to touch. With gun shot wound scar at right lower quadrant of the abdomen and exploratory laparotomy scar at the midline, Nails are clean, light pink in color, no clubbing and no nail plate abnormalities noted. his capillary refill is >3 sec. HEENT Cranium Hair is black in color, abundant, well distributed, smooth and has a dry texture. The scalp is slightly movable along the cranium, no lesion and no lice. Sutures are not palpable. The cranium is normocephalic, symmetrical and has no deformities. No tenderness and no masses. Temporal arteries not visible but palpable with weak pulsations. Face It is assymmetrical, no abnormal facies seen. Skin is brown in color, smooth and no lesions. Face has no involuntary movements. Eyes Eyebrows are black in color and well distributed. Eyelashes are black, short, present on both upper and lower eyelids. Eyelids have no lesions, no edema and negative for lid lag. Palpebral fissure is 4cm in diameter. Eyeballs have no sign of exopthalmos and enopthalmus. Periorbital area not sunken, no swelling and no hematoma. Conjunctiva are pale in color, no edema and no lesions. Patient has cataract on both eyes. Iris is round and black in color. Pupils
Image of page 3
are round, symmetrical and about 3mm upon constriction, reactive to both direct and consensual reflex. Visual fields, visual acuity and Fundoscopic examinations were not assessed. Ears External ears are C-shaped, symmetrical, no deformities, no lesion and no tenderness over the auricles and mastoid area. External auditory canal is patent, walls are pinkish in color, with abundant cerumen, no discharges and no foreign bodies. Otoscopic test was not performed. Nose It is symmetrical and no visible flaring of ala nasi. Vestibule is patent, mucosa is pinkish in color, with no secretions and no bleeding. Nasal septum is straight at the midline and no perforations. No tenderness and clouding of paranasal sinuses upon Transillumination.
Image of page 4

Info icon This preview has intentionally blurred sections. Sign up to view the full version.

View Full Document Right Arrow Icon
Image of page 5
This is the end of the preview. Sign up to access the rest of the document.

{[ snackBarMessage ]}

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