No hemorrhage or exudate seen on fundoscopic exam disc margins sharp no cupping

No hemorrhage or exudate seen on fundoscopic exam

This preview shows page 4 - 6 out of 7 pages.

avascular, lens transparent, red reflex noted. No hemorrhage or exudate seen on fundoscopic exam, disc margins sharp, no cupping or edema noted; vision 20/20 on visual acuity exam with corrective lenses. TM is translucent, pearly-grey- light reflex and bony landmarks present bilaterally without erythema or effusion. External auditory canal is patent, no swelling noted; no hearing impairments noted on whisper, Rinne or Weber tests. Nares patent bilaterally, no polyps noted. Nasal mucosa pink without rhinorrhea, no sinus tenderness noted. Oropharynx without erythema or exudate. Buccal mucosa intact without lesions. Gums pink without inflammation. All teeth present without caries. Tonsils and adenoids present without erythema or exudate. Positive gag reflex. Uvula midline. CN X intact. Neck: Supple, full ROM, no thyromegaly, cervical and clavicular nodes palpable without tenderness. No tracheal deviation noted. No carotid bruits, no masses noted on palpation. Jugular venous pressure is measured at 8cm with patient at 45 degrees. No JVD noted. Chest/Lungs/Heart : Thorax symmetrical with vesicular breath sounds, scattered rales throughout all lung fields. No rhonchi or wheezes heard. Labored respirations at 22. No accessory muscle use noted. No cyanosis or nasal flaring. Heart rate regular with good S1 and S2. S3 noted. 3/6 systolic murmur noted. Respiratory excursion not assessed due to SOB. Breasts negative for masses, retractions, dimpling, tenderness or pain. No swollen axillary nodes. PMI/apical pulse without heaves or lifts. Fingernails without cyanosis or clubbing. Capillary refill < 3 seconds PV : 3+ peripheral edema noted extending to knees bilaterally. 2+ dorsalis pedis pulses palpated bilaterally. Abdomen: normoactive bowel sounds + x 4 quads. Abdomen appears distended. No masses palpated. No Splenomegaly, liver enlargement, or tenderness noted. Genital/Rectal : Normal rectal sphincter tone. No rectal masses or tenderness. Stool is brown. Pelvic exam reveals normal external genitalia. Prostate is firm, smooth and slightly moveable. Nontender with a diameter of approximately 4 cm. Musculoskeletal : Spine vertically aligned, normal S-curve. BUE and BLE symmetrical. Full ROM noted in all joints. 5/5 strength noted in all muscle groups Neurological : Alert and oriented X 3. Anxious, affect appropriate. CN II-XII intact. Extremity sensory intact to pin prick, bicep, brachioradialis, triceps, patellar and Achilles tendon. DTR 2+ bilaterally Skin : Intact, cool and dry. No bruises, rashes, tattoos or lesions noted. Midline scar to chest from open heart surgery.
Image of page 4
Diagnostic results : Careful evaluation of the patient's history and physical examination (including signs of congestion, such as jugular venous distention [JVD]) can provide important information about the underlying cardiac abnormality in heart failure. According to Dumitru (2016), the American College of Cardiology/American Heart Association (ACC/AHA), Heart Failure Society of America (HFSA), and European Society of Cardiology (ESC) recommend the following basic laboratory tests and studies in the initial evaluation of patients with suspected heart failure:
Image of page 5
Image of page 6

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture