Ears : Bilateral external ears no lesions, masses, drainage or tenderness. Tympanic membranes intact, pearly gray, no bulging, no erythema, and landmarks appreciated bilaterally. Hearing intact bilaterally. Nose : No nasal flaring, greenish discharge, no obstruction, septum not deviated. Turbinate’s erythematous and moist. No polyps or lesions bilaterally. Nares patent Throat: Oropharynx with greenish drainage and mucosa moist. Slight erythema present Mouth: No lesions, no thrush. Moist mucous membranes. Healthy dentition present. Tongue midline. Neck: +tightness, + tenderness. Full range of motion with difficulty. Trachea midline. No masses. Thyroid and lymph nodes not palpable. Chest/Lungs: Thorax non-tender with symmetric expansion. No accessory muscle usage. No tenderness or nodules present with palpation of breast fields. No edematous axillary nodes present. Respiration regular and unlabored at 16, no cough present. Tactile fremitus equal bilaterally and greater in upper lung fields. Breath sounds; no adventitious lung sounds. All lung fields with resonant percussion tones. Heart: Regular rate, and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Apical pulse not visible. JVP appears to be approximately less than 6 cm with HOB elevated to 45 degrees. No carotid bruits or JVD appreciated. Capillary refill<2secs all extremities. Peripheral Vascular: Pulses 2+ bilateral pedal and 2+ radial bilaterally. No pedal edema. Popliteal pulses 2+ bilaterally. Abdomen: Abdomen round, soft, and non-tender to palpation. No palpable mass, hepatomegaly or splenomegaly. Active bowel sounds all quads. Tympany over most quadrants with scattered areas of dullness noted upon percussion. No abdominal bruits. Genital/Rectal: Adequate tone, no masses noted, eternal genitalia intact. Musculoskeletal : Normal passive and active ROM in upper and lower extremities. No focal joint inflammation or abnormalities appreciated in upper and lower extremities. Normal alignment of hips and knees bilaterally. All upper and lower extremity joints without effusions or erythema. Spine vertically aligned. Normal S-curvature. No nodules, masses or tenderness with palpation. Normal muscle strength against resistance. Neurological: CN ll-Xll grossly intact. Awake, alert, and oriented to person, place and time. Patient can move all limbs on command and spontaneously. Motor strength 5/5, walking in straight line without weakness, tenderness or vertigo. Skin: Warm, dry and intact. Skin is tanned. No edema. No peripheral cyanosis. No clubbing. Skin integrity intact, no ecchymosis. Nail beds are pink and blanch evenly. ASSESSMENT: Sinus, Skull X-ray series; CT scan of sinus, MRI; CBC, CMP/ESR CRP Differential Diagnosis:
Sinus Headache The etiology of sinusitis is rhinosinusitis. Rhinosinusitis is a condition characterized by thick, yellow/green nasal discharge, with a foul odor and presents with facial pain or pressure over the sinuses, nose, and cheekbones and can cause photosensitivity ( Petersen, Jull, & Learman, 2019). The pain can radiate to the back of the head and into the shoulders. Caused by a microorganism, fever is usually present as well as malaise and commonly fever ( Favoni, Pierangeli, Cirillo, Toni, Abu-Rumeileh, Morgia, & Cevoli, 2019). Facial pain and headache
You've reached the end of your free preview.
Want to read all 9 pages?
- Summer '15