Escolar Documentos
Profissional Documentos
Cultura Documentos
PHYSICAL EXAMINATION
Day 1: September 16, 2015 (1:15
pm)
GENERAL APPEARANCE: Seen
patient on the bed awake, alert,
responsive, and coherent with ISA
on his left arm, with the following
vital signs:
BP=130/70mmHg
PR=102bpm
RR=36cpm
Temperature=37.1C/axilla
ANTHROPOMETRIC
MEASUREMENTS:
Weight: 47kg (103.4lbs)
Height: 46 (1.39m)
BMI: 24.32 (overweight)
IBW: 42.7kg (94 lbs)
BMI Categories:
Underweight = <18.5
Normal weight = 18.524.9
Overweight = 2529.9
Obesity = BMI of 30 or greater
SKIN: Dark brown, evenly colored
skin tone. Skin is dry and warm. Skin
is thin with calluses noted on plantar
surface of both feet. Skin pinches
easily and immediately return to its
original position. Hematomas 15 mm
in diameter are seen on both upper
and lower extremities due to
previous IV injection site. With ISA
on his left hand.
PERIPHERAL PULSES:
(R)
Pulse
Temporal
Amplitude
101
Scale
+2
0 = Absent
Carotid
+1 = Weak
103
+2 = Normal
+2
+3 = Increased
Brachial
+4 = Bounding
104
+2
Radial
101
+3
Popliteal
101
+2
Posterior
tibialis 101
+2
Dorsalispedis
103
+2
ABDOMEN: Rounded and
symmetric without bulges. Striae not
noted. Umbilicus is at midline,
depressed and without bulging. Soft
gurgles and clicks heard all
throughout the quadrants of the
abdomen. Percussion tone is
tympany. Girth is 92 cm. No fluid
wave is transmitted. The borders
between tympany and dullness
remain relatively constant
throughout position changes.
34
12
24
Muscle
strength:
(R)
(L)
5/5 4/5
4/5
4/5
Scale:
5 Full
ROM
against
gravity,
full
resistanc
e
4 Full
ROM
against
gravity,
some
resistanc
e
3 Full
ROM
with
gravity
2 Full
ROM
with
gravity
eliminate
d
(passive
motion)
1 Slight
Reaction
0 No
Reaction
NEUROLOGIC ASSESSMENT
Mental Status/ Cerebral Function:
Client is awake, responsive, alert,
and cooperative, appears to be
relaxed, and maintains eye contact.
Client states nickname Marky
CN 12 (Hypoglossal): Protrudes
tongue in midline, able to push
tongue depressor in left & right side
of the mouth without difficulty
DEEP TENDON REFLEXES:
Biceps
Grading Deep
Tendon
(R) +2 Reflexes
+4
hyperactive,
(L) +2
very
brisk,
Triceps
rhythmic
oscillations
(R) +2 (clonus);
abnormal and
(L) +2
indicative
of
Brachioradialis disorder
(R) +2
+3 more
(L) not
brisk or active
assessed due
than normal,
to ISA
but
not
attached
indicative
of
disorder
Patellar
+2 normal,
(R) +2
usual
(L) +2
response
+1
Achilles
decreased,
(R) +2
less
active
(L) +2
than normal
0
no
response
Day 2: September 17, 2015
(2:30pm)
GENERAL APPEARANCE: Seen
patient on the bed awake, alert,
No
Reaction