Você está na página 1de 4

Recording Behavior and Mental Status

Mental Status: The patient is alert, well:groomed, and cheerful. Speech is fluent and words are clear.
Thought processes are coherent, insight is good. The patient is oriented to person, place, and time. Serial 7s
accurate; recent and remote memory intact. Calculations intact.
Mental Status: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are
mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is
oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed.
Clock drawing is good.

Recording The Skin, Nail, and Hair Physical Examination

Number: solitary or multiple; estimate of total number
Size: measured in millimeters or centimeters
Color: including erythematous if blanching; if nonblanching, vascular:like cherry angiomas and
vascular malformations, petechiae, or purpura
Shape: circular, oval, annular, nummular, or polygonal
Texture: smooth, fleshy, verrucous or warty, keratotic; greasy if scaling
Primary lesion: flat, a macule or patch; raised, a papule or plaque; or fluid filled, a vesicle or bulla (may
also be erosions, ulcers, nodules, ecchymoses, petechiae, and palpable purpura)
Location: including measured distance from other landmarks
Configuration: grouped, annular, linear

Skin warm and dry. Nails without clubbing or cyanosis. Approximately 20 brown, round macules on upper
back, chest, and arms, are all symmetric in pigmentation, none suspicious. No rash, petechiae, or
Marked facial pallor, and circumoral cyanosis. Palms cold and moist. Cyanosis in nail beds of fingers and
toes. Numerous palpable purpura on lower legs bilaterally.
Scattered stuck-on verrucous plaques on back and abdomen. Over 30 small round brown macules with
symmetric pigmentation on back, chest, and arms. Single 1.2 1.6 cm asymmetric dark brown and black
plaque with erythematous, uneven border, on left upper arm.
Facial plethora. Skin icteric. Many telangiectatic mats on chest and abdomen. Single 5 mm pearly papule
with rolled border on left zygomatic cheek. Nails with clubbing but no cyanosis.

Recording the Physical Examination: The Head, Eyes, Ears, Nose, and Throat (HEENT)
HEENT: HeadThe skull is normocephalic/atraumatic (NC/AT). Hair with average texture. EyesVisual
acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Pupils are 4 mm constricting to 2 mm, equally round
and reactive to light and accommodations. Disc margins sharp; no hemorrhages or exudates, no arteriolar
narrowing. EarsAcuity good to whispered voice. Tympanic membranes (TMs) with good cone of light.
Weber midline. AC > BC. NoseNasal mucosa pink, septum midline; no sinus tenderness. Throat (or
Mouth)Oral mucosa pink, dentition good, pharynx without exudates.
NeckTrachea midline. Neck supple; thyroid isthmus palpable, lobes not felt.
Lymph NodesNo cervical, axillary, epitrochlear, inguinal adenopathy.
HeadThe skull is normocephalic/atraumatic. Frontal balding. EyesVisual acuity 20/100 bilaterally.
Sclera white; conjunctiva injected. Pupils constrict 3 mm to 2 mm, equally round and reactive to light and
accommodation. Disc margins sharp; no hemorrhages or exudates. Arteriolar-to-venous ratio (AV ratio) 2:4;
no AV nicking. EarsAcuity diminished to whispered voice; intact to spoken voice. TMs clear. Nose
Mucosa swollen with erythema and clear drainage. Septum midline. Tender over maxillary sinuses. Throat
Oral mucosa pink, dental caries in lower molars, pharynx erythematous, no exudates.
NeckTrachea midline. Neck supple; thyroid isthmus midline, lobes palpable but not enlarged.
Lymph NodesSubmandibular and anterior cervical lymph nodes tender, 1 cm 1 cm, rubbery and
mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy.

Recording the Physical ExaminationThe Thorax and Lungs

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles, wheezes,
or rhonchi. Diaphragms descend 4 cm bilaterally.
Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are
hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes.
Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm

Recording the Cardiovascular Examination

The JVP is 3 cm above the sternal angle with the head of bed elevated to 30. Carotid upstrokes are brisk,
without bruits. The PMI is tapping, 1 cm lateral to the midclavicular line in the 5th intercostal space. Crisp
S1 and S2. At the base, S2 is louder than S1 with physiologic split of A2 > P2. At the apex, S1 is louder than
S2. There are no murmurs or extra sounds.
The JVP is 5 cm above the sternal angle with the head of bed elevated to 50. Carotid upstrokes are brisk; a
bruit is heard over the left carotid artery. The PMI is diffuse, 3 cm in diameter, palpated at the anterior
axillary line in the 5th and 6th intercostal spaces. S1 and S2 are soft. S3 is present at the apex. High-pitched
harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla.

Recording the Breasts and Axillae Examination

Breasts symmetric and smooth without nodules or masses. Nipples without discharge.
Breasts pendulous with diffuse fibrocystic changes. Single firm 1 1 cm mass, mobile and nontender, with
overlying peau dorange appearance in right breast, upper outer quadrant at 11 oclock, 2 cm from the

Recording the Abdominal Examination

Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable masses or
hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm
below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.
Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with increased tenderness, guarding, and
rebound in the right midquadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen
and kidneys not felt. No palpable masses. No CVA tenderness.

Recording the Physical ExaminationThe Peripheral Vascular System

Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and
nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and
posterior tibial (PT) pulses are 2+ and symmetric.
Extremities are pale below the midcalf, with notable hair loss. Rubor noted when legs dependent but no
edema or ulceration. Bilateral femoral bruits; no abdominal bruits heard. Brachial and radial pulses 2+;
femoral, popliteal, DP and PT pulses 1+.

Recording the ExaminationThe Musculoskeletal System

Full range of motion in all joints of the upper and lower extremities. No evidence of swelling or deformity.
Full range of motion in all joints. Hand with Heberden nodes at the DIP joints, Bouchard nodes at PIP
joints. Mild pain with flexion, extension, and rotation of both hips. Full range of motion in the knees, with
moderate crepitus; no effusion but bony enlargement along the tibiofemoral joint line bilaterally. Both feet
with hallux valgus at the first MTP joints.
Right knee with moderate effusion and tenderness over medial meniscus along the joint line. Moderate
laxity of ACL on Lachman test; PCL, MCL, and LCL intactno posterior drawer sign or tenderness with
varus or valgus stress. Patellar tendon intactpatient able to extend lower extremity. All other joints with
good range of motion; no other deformity or swelling.

Recording the ExaminationThe Nervous System

Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and
time. Detailed cognitive testing deferred. Cranial Nerves: Inot tested; II through XII intact. Motor: Good
muscle bulk and tone. Strength 5/5 throughout. CerebellarRapid alternating movements (RAMs), finger-
to-nose (FN), heel-to-shin (HS) intact. Gait with normal base. Rombergmaintains balance with eyes
closed. No pronator drift. Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2 and
symmetric with plantar reflexes downgoing.
Mental Status: The patient is alert and tries to answer questions but has difficulty finding words. Cranial
Nerves: Inot tested; IIvisual acuity intact; visual fields full; III, IV, VIextraocular movements intact;
V motortemporal and masseter strength intact, corneal reflexes present; VII motorprominent right facial
droop and flattening of right nasolabial fold, left facial movements intact, sensory taste not tested; VIII
hearing intact bilaterally to whispered voice; IX, Xgag intact; XIstrength of sternocleidomastoid and
trapezius muscles 5/5; XIItongue midline. Motor: strength in right biceps, triceps, iliopsoas, gluteals,
quadriceps, hamstring, and ankle flexor and extensor muscles 3/5 with good bulk but increased tone and
spasticity; strength in comparable muscle groups on the left 5/5 with good bulk and tone. Gaitunable to
test. Cerebellar unable to test on right due to right arm and leg weakness; RAMs, FN, HS intact on
left. Rombergunable to test due to right leg weakness. Right pronator drift present. Sensory: decreased
sensation to pinprick over right face, arm, and leg; intact on the left. Stereognosis and two-point
discrimination not tested. Reflexes: