Distal pulses 2+, symmetrical, dorsalis pedis and posterior tibial. There was mild to moderate epigastric tenderness to deep palpation.ĮXTREMITIES: Femoral pulses 2+, symmetrical. No guarding, rigidity, organomegaly or masses. LUNGS: Clear to auscultation and percussion. VITAL SIGNS: Blood pressure 114/86 and pulse 82. GENERAL: This is a pleasant male in no acute distress. LYMPHATICS: The patient does have lymphadenopathy along the anterior cervical chain. PSYCHIATRIC: The patient is alert and oriented x4. LUNGS: Clear to auscultation bilaterally.ĪBDOMEN: Soft, nontender, and nondistended with positive bowel sounds.ĮXTREMITIES: Have no clubbing, cyanosis or edema. Tonsils are inflamed with a slight amount of exudate. HEENT: Pupils are equal, round, and reactive to light. GENERAL: The patient is alert and oriented x4, in no acute distress. VITAL SIGNS: Blood pressure is 142/84 with a pulse rate of 97, respiratory rate of 20, temperature of 98.6, and O2 saturation of 97%. Psychiatric: She does appear to be a little bit morose. Musculoskeletal: She has a full range of motion, good muscle bulk and tone of all her extremities. Lymphatic: Lymph nodes are not present in the neck, axilla nor groin. Lungs: Clear posteriorly, perhaps some dullness in the bases. Pupils are equal, round, and reactive to light and accommodation. HEENT: Head is normocephalic, atraumatic. General: She is a slightly overweight woman in some distress. PHYSICAL EXAMINATION: Vital Signs: Temperature 99.6, blood pressure 156/98, pulse 114, O2 saturation 94%. No splenomegaly, no hepatomegaly, no peritoneal signs, no rebound or guarding.ĮXTREMITIES: Without clubbing, edema or cyanosis. No difficulty breathing.ĪBDOMEN: Soft and nontender. LUNGS: Clear to auscultation bilaterally. No exudate, no submandibular anterior or posterior auricular lymphadenopathy. Oropharynx is with some slight erythema, mild edema to the tonsillar pillars and uvula. Tympanic membranes are intact, nonerythematous and nonbulging. Pupils are equal, round, and reactive bilaterally. GENERAL: The patient is alert and oriented x3, in no apparent distress. VITAL SIGNS: Blood pressure 124/79 pulse was recorded by triage as 122, pulse retaken by myself was 108 respirations 19, temperature 101.5. EXTREMITIES: No edema, no varicose veins. CHEST: Clear to auscultation and percussion.ĬARDIAC EXAM: Cardiac impulse feels normal. NECK: Carotid pulses are full and without bruit. GENERAL: He is a well-nourished, well-developed (XX)-year-old male complaining of 7/10 chest pain, who appears acutely ill. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure: 122/78. PSYCHIATRIC: The patient is pleasant and cooperative with an appropriate mood and affect. MUSCULOSKELETAL: The patient moves all extremities well and ambulates independently. HEART: Regular rate and rhythm with no murmurs, rubs or gallops. LUNGS: Clear to auscultation bilaterally with the exception of a few crackles in the right base that clear with cough. Pupils are equal, round, reactive to light. GENERAL: The patient is a well-developed, well-nourished female in no acute distress. VITAL SIGNS: Temperature 98.6, respirations 16, pulse 84, BP 114/78, O2 sat 100% on room air. EXTREMITIES: Negative for cyanosis, clubbing or edema. ABDOMEN: Soft, nontender, and nondistended with normal bowel sounds. LUNGS: Scant rales appreciated at the bases bilaterally. There is grade 1/6 systolic murmur heard over the left sternal border. First and second heart sounds are regular and of normal intensity. Carotid upstrokes seem normal bilaterally with a very soft bruit auscultated on the right. NECK: There is no jugular venous distention. VITAL SIGNS: Blood pressure 142/52 mmHg, pulse regular at 20 beats per minute, respirations unlabored at 20 breaths per minute, and temperature currently afebrile. PHYSICAL EXAMINATION: GENERAL: The patient is well developed, thin, in no apparent distress. NEUROLOGIC: Cranial nerves II through XII are intact. No rebound, no guarding, no peritoneal signs.ĮXTREMITIES: Without clubbing, cyanosis or edema. No murmurs, rubs or gallops.ĪBDOMEN: Active bowel sounds are present. Pupils are equal, round, and reactive to light bilaterally. GENERAL: The patient is awake, alert and oriented x3, although drowsy. VITAL SIGNS: Blood pressure 132/84, pulse 92, respirations 17, temperature 98.5, pulse oximetry 98% on room air.
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