PHYSICAL EXAMINATION:
GENERAL: Currently, the patient is awake and alert, appears in no apparent distress.
VITAL SIGNS: Temperature 98.4, pulse 92, respiratory rate 18, and blood pressure 144/68. Saturations are 94%, currently on 4 liters.
HEENT: Pupils are equal and reactive. Tympanic membranes are clear. Oropharynx is clear.
NECK: Supple. There is no JVD.
LUNGS: She has bilateral wheezes with rhonchi. She has a moist rhonchorous cough that is easily heard with secretions mainly in the bronchus.
CARDIAC: Regular rate and rhythm. No obvious S3 or S4. She wheezes audibly.
ABDOMEN: Soft, nontender, and morbidly obese.
EXTREMITIES: Pitting edema 2+, to the level of the thigh.
NEUROLOGIC: She moves all extremities and appears intact.
PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is an (XX)-year-old female who is comfortable in the stretcher, in no specific distress. She is awake, alert and oriented x 3. VITAL SIGNS: Temperature 98.6, pulse 66, respirations 18, blood pressure 136/58, O2 saturation 100%. SKIN: Warm and dry, no rashes, normal turgor. HEENT: Head is normocephalic and atraumatic. Eyes are PERRLA. EOMs are full. Conjunctivae are clear. TMs intact, no hemotympanum, normal hearing. Throat is clear. Moist membranes. NECK: Supple, full range of motion. LYMPHATICS: No cervical or axillary adenopathy. LUNGS: Clear bilaterally, normal respiratory effort. HEART: Normal S1 and S2 without murmurs, rubs or gallops. ABDOMEN: There is a healed scar in lower abdomen with distension and obesity. Otherwise, soft with bowel sounds active. Vague discomfort without rebound or guarding. No organomegaly. RECTAL: Deferred. GENITOURINARY: Deferred. BACK: No CVA or spinal tenderness. EXTREMITIES: No edema, cyanosis or clubbing. NEUROLOGIC: Intact. No focal findings.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/58, pulse 76, respirations 14, and temperature is 98.4.
GENERAL: The patient is an elderly female who is well developed. She appears frail.
HEENT: Pupils are round, reactive to light. Extraocular movements are intact. Tympanic membranes are obscured by cerumen. Mouth and pharynx is normal.
NECK: Without lymphadenopathy or thyromegaly. There are no carotid bruits.
LUNGS: Clear to auscultation, except they are decreased at the right base.
HEART: S1, S2. No S3, S4, or murmur.
ABDOMEN: Soft. Normal bowel sounds. No hepatosplenomegaly.
BREASTS: Her right breast is normal. There is some shotty right axillary lymphadenopathy. The left breast is mildly engorged, especially around the areola. There is no actual palpable mass at that site. She does have some shotty left axillary lymphadenopathy.
EXTREMITIES: Her left upper extremity is notable for 2 to 3+ lymphedema. Otherwise, there is no erythema and her pulses are intact. Her lower extremities, 3+ edema of the right lower extremity with pitting edema. Do not feel a pulse, but the skin temperature is identical to the left lower extremity. The left lower extremity, she had has a good dorsalis pedis pulse. She has 1 to 2+ edema. No palpable cords.
NEUROLOGIC: Alert and oriented x3. Cranial nerves II through XII are normal. Deep tendon reflexes are symmetrical. Babinskis are absent.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 120/78, pulse 72, respirations 18, O2 saturation 98%. I and O’s 600 in and 1200 out, all urine output.
GENERAL: Pleasant male, in no acute distress.
HEENT: EOMI. Oropharynx is clear. Sclerae are anicteric. Conjunctivae are not pale.
NECK: No carotid bruits. No thyromegaly.
CARDIAC: RRR. No murmurs or rubs.
LUNGS: CTA bilaterally with normal respirations.
ABDOMEN: Positive bowel sounds, soft, nontender. No HSM.
EXTREMITIES: 1+ pitting edema bilaterally.
SKIN: Without rashes.
NEUROLOGIC: Alert and oriented x3 and nonfocal exam.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 68, respirations 16, blood pressure 106/68, saturating 100% on room air, temperature 98.6.
GENERAL: In some distress secondary to pain.
HEENT: Her head is atraumatic, normocephalic. Sclerae are anicteric.
NECK: Supple. There is no cervical adenopathy. No supraclavicular adenopathy. Thyroid is without masses.
LUNGS: Clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nondistended. Normoactive bowel sounds with mild tenderness and fullness in the right lower quadrant. Inguinal orifices are clear. Distal pulses are palpable. No costovertebral tenderness. No peritoneal signs.
EXTREMITIES: Without edema.
PHYSICAL EXAMINATION: General: She is well developed and well nourished at the present time. Vital Signs: Blood pressure 218/82 with pulse rate of 82 and respiratory rate 16. She is afebrile. HEENT: Pupils equal, round, and reactive to light. EOMs intact. TMs intact bilaterally. Neck: Supple without cervical lymphadenopathy. Lungs: Clear to percussion and auscultation. Heart: She has normal S1 and S2 without murmurs or gallops. Abdomen: Soft and nontender. There are no masses. Extremities: She has no pedal edema or cyanosis. Neurologic: She does have a slurred speech.
PHYSICAL EXAMINATION:
GENERAL: The patient is a very pleasant elderly female. She is awake, alert, and oriented x3. She is not in any acute distress right now.
VITAL SIGNS: Temperature 97.8, pulse 56 per minute, respirations 18, blood pressure 176/64.
HEENT: PERRLA. Pupils are equal, round, and reactive to light and accommodation. No scleral icterus. No conjunctival injection.
NECK: Supple. No JVD. No thyromegaly. No lymphadenopathy. No carotid bruits.
HEART: Sounds are normal. S1, S2. No S3.
LUNGS: Clear to auscultation and percussion.
ABDOMEN: She has right upper quadrant and right umbilical scar from her previous gallbladder surgery and she has a mild bulge around the incision, possibly abdominal wall hernia. Bowel sounds positive. Normoactive. No tenderness, no organomegaly.
EXTREMITIES: Without edema or cyanosis. No calf tenderness. There are scars on both knees for total knee replacements.
NEUROLOGICAL: No neuromotor deficits.
