PHYSICAL EXAMINATION: GENERAL: The patient is alert, awake, and in no marked distress. VITAL SIGNS: Temperature 97.4 degrees, pulse 100, respirations 18, blood pressure 142/72. HEENT: PERRL. EOM intact. No abnormal ENT masses or discharges. No icterus. Mouth: Good dentition. No oral lesions. Moist mucous membranes. NECK: No adenopathy or thyromegaly. Nontender. LUNGS: Decreased breath sounds on the left lower one-third hemothorax, otherwise clear. No palpable crepitus. No wheezes. No rales. There is a moderate amount of ecchymosis in the left chest wall and tenderness in the left chest wall laterally. HEART: Regular rate and rhythm without murmur. No palpable thrills. BREASTS: The left breast is ecchymotic but not swollen. No palpable masses. No skin or nipple changes. No nipple discharges. No axillary adenopathy. LYMPHATICS: No cervical, axillary, or inguinal lymphadenopathy. ABDOMEN: Soft, flat, and nontender. Bowels sounds normal. No abnormal masses or hepatosplenomegaly. No umbilical or groin bulges. RECTAL: The patient declined. EXTREMITIES: No deformity or edema. SKIN: No rash and good turgor. PSYCHIATRIC: Alert, awake, and oriented to person, place, and time with appropriate mood and affect.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 142/96, pulse 102, respiratory rate 18, temperature 97.8, and pulse ox is 97% on room air.
GENERAL: The patient is awake, alert, and oriented, in no apparent distress, resting comfortably on the bed. She has a very nasal voice.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae are nonicteric. Conjunctivae are clear. Oropharynx is clear and pink with moist mucous membranes. Her tympanic membranes have a serous fluid behind both of them, but there is no thickening of the tympanic membrane on either side. She has no opacity. No redness.
NECK: Supple without lymphadenopathy. No tracheal deviation. She does have some mild thyromegaly.
LUNGS: Clear to auscultation bilaterally. No wheezes, rubs, rhonchi, rales, or stridor.
HEART: Normal S1, S2. Regular rate and rhythm, no murmurs.
ABDOMEN: Normoactive bowel sounds, soft, nontender, nondistended, no masses, no hepatosplenomegaly.
EXTREMITIES: With full range of motion in all four extremities, no joint swelling or redness.
SKIN: Warm and dry, no evidence of rash.
NEUROLOGIC: Intact. Moving all four extremities symmetrically and spontaneously and is following commands. She is speaking in full, fluent sentences.
PHYSICAL EXAMINATION:
GENERAL: The patient is an elderly Hispanic female, alert, in no acute distress.
VITAL SIGNS: Blood pressure 168/84, heart rate 90, and respiratory rate 20 on pressure support of 15 with tidal volumes of 450-600 and minute ventilation of 9-10 liters, and temperature 98.6 degrees.
HEENT: The patient has a Shiley size #8 tracheostomy tube in the midline. Posterior pharynx is clear. Nasopharynx shows a small amount of clear nasal drainage. Conjunctivae clear.
CHEST: She has bilateral coarse rhonchi. Prolonged I:E ratio. No stridor. No use of accessory muscles at rest.
CARDIOVASCULAR: Difficult to auscultate over the breath sounds. She has a regular rate and rhythm. No murmur or gallop is appreciated. No palpable heaves or thrills.
ABDOMEN: Soft. She complains of some mild epigastric tenderness with palpation. No guarding. No palpable masses. Normoactive bowel sounds.
EXTREMITIES: She has no clubbing or cyanosis. She has a trace edema of the lower extremities. No discrepancy in cast size.
NEUROLOGIC: She is alert and oriented. She has incomplete quadriparesis with some severe left lower extremity weakness with minimal mobility to move the toes unopposed and right-sided weakness of lower extremities with ability to raise her knee off the bed unopposed.
PHYSICAL EXAM: Vital signs revealed a blood pressure of 106/62, respirations of 16 breaths per minute, and a pulse rate of 72 beats per minute. On neurologic examination, the patient is alert and oriented. Simple attention is intact. Sustained attention, however, is poor. The patient has difficult registering four-word pairs, but does it after three trials. At one minute, the patient recalls none spontaneously and gets three with cueing after five minutes. He recalls one of four word pairs spontaneously. He gets to three with multiple-choice cues. Interestingly, he can count from 40 to 0 with no mistakes or errors in about 40 seconds. Word list generation is 13 in a category, which is substandard. Long-term memory is mildly impaired for past presidents, past/current events, etc., and details about local politics. Language is fluent. Visuospatial was not examined, and comprehension was normal. Problem solving is moderately impaired. Insight is moderately impaired, and organization and executive skills are moderately impaired with moderate impairment in safety awareness. He is, however, able to generate some problems solving and is able to generate consequences to some decisions that need to be made such as the ability to live at home and direct his own care. He says last night that when he was confusional or agitated, he was in fact refusing to have the IV medications given to him, but they were given anyway. His cranial nerve examination reveals mildly saccadic pursuits for full vertical and horizontal ductions. Fundi could not be well visualized. Fields are full. He has negative glabellar, negative jaw jerk. The rest of his cranial nerves were intact. He has no nuchal rigidity. His motor examination shows symmetric strength throughout with no cogwheeling, mild bradykinesia with no severe akinesia. No tremor at rest. Reflexes are 2+ throughout. Toes are equivocal. He does not have primary sensory loss to vibration, JPS, or pinprick that we could tell. The patient goes from sit to stand by pushing on the wheelchair and cannot arise without doing that. He has very narrow limits of stability posteriorly and delayed step response. He ambulates in a crouched suspensory posture and has mild freezing when he starts out, but no freezing on turns. Turns are not particularly wide. He has no festination in his gait. Of note, he is not hypomanic. He does not have decreased blink frequency, and he has a negative glabellar.
PHYSICAL EXAMINATION: General: The patient is a well-developed and well-nourished (XX)-year-old, awake, alert, and oriented x3 with mild distress. Vital Signs: Blood pressure is 136/86 mmHg, pulse is 72 beats per minute, respirations are 18 breaths per minute, and the patient is afebrile. Skin: Warm and dry. HEENT: Normocephalic and atraumatic. PERRLA. The fundi are more or less okay. The conjunctivae are pink, and the sclerae are anicteric. Neck: Supple. There is full range of motion. The carotids are 2+ bilaterally without any bruits being heard. The lymph nodes are negative. Thyroid is nonpalpable. The trachea is midline. Heart: Regular sinus rhythm without murmur, gallop, or rub. Lungs: Clear to P&A. Abdomen: Normoactive bowel sounds, soft, positive tenderness in the left lower quadrant. There is no liver, kidney, or spleen and no other masses palpated. The abdominal aorta is palpated and is pulsatile but appears to be otherwise without an aneurysm. Extremities: No clubbing, cyanosis, or edema. She does have some varicose veins in the extremity. Neurologic/Psychiatric: There are no acute changes.
