lumps Menopause; hot flashes; post- menopausal bleeding; NA Peripheral Vascular Claudication; leg cramps; varicose veins; hx of blood clots Negative Musculo- skeletal Muscle or joint pain; joint stiffness Negative Neuro Syncope; seizures; weakness; paralysis; numbness/tingling; tremors; involuntary movements Negative Heme Hx of anemia; easy bruising or bleeding; blood transfusions Negative Endo Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size Negative Psych Nervousness/anxiety; depression; memory changes; suicide attempts Negative 4
General Findings and Physical Exam General Observations Does patient appear to be their stated age? Patient appears younger than stated age Level of consciousness A/Ox4 Skin color Appropriate for ethnicity Nutritional status Good nutritional status Posture and position Sitting up, relaxed Obvious physical deformities None noted Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement Steady on feet, no assistive devices Facial expression Relaxed Mood and affect Relaxed Speech: articulation, pattern, content and appropriate, native language Speech clear Hearing Hearing appropriate Personal hygiene Well groomed Measurements and Vital Signs Weight 170lbs Height 5’10” BMI 24 Radial pulse: rate rhythm Regular rhythm and rate for radial pulse 5
Respirations: rate depth Regular rate and depth for respirations, none labored Blood pressure (indicate if sitting or lying) Patient reports last BP 120/67 Temperature (if indicated) 97.6 temporal Pain assessment Denies pain Skin Hands and nails No open sores or cuts noted on hands, nails short and clean Color and pigmentation Pigment appropriate for ethnicity Temperature Warm to touch Moisture Moist Texture Smooth Turgor Good skin turgor on back of hands Presence of lesions? None Head and Face Scalp Hair Cranium Hair distributed appropriately, no dryness noted. Normal cephalic. Face (cranial nerve VII) Cranial nerves intact Temporal artery and temporomandibular joint Temporal artery felt, no bounding or pain noted. TMJ intact, no grinding or pain noted Maxillary sinuses and frontal sinuses No tenderness with palpation of sinuses Eyes Visual fields (cranial nerve II) Visual fields intact. Visual acuity 20/20. Extraocular muscles, corneal light reflex, and No nystagmus noted, patient able to follow finger correctly/ 6
cardinal positions of gaze (cranial nerves III, IV, VI) External structures No abnormalities, open areas noted Conjunctivae, sclerae, and corneas Conjunctivae white, no redness or discharge noted. Pupils Pupils ERRL, accommodate Describe the purpose of an Opthalmascope for assessing the eyes The opthalmascope is used to exam the eyes, check for glaucoma or retinal detachment or other diseases. It looks at the back of the eye, retina, blood vessels, nerves and optic disk.
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- Fall '18
- pulse, bounding pulse