Abstract Throughout this complete health assessment, I will approach my patient, a 49 years old, female, married patient, and perform a head to toe examination.
Starting with the gathering of information, I will start with biographic data, reason for seeking care, present illness, past health history, family history, functional assessment, perception of health, head to toe examination, and baseline measurements. The subjective data will be collected first, where the patient will provide necessary information about every organ system for further examination while the objective data will be amassed in every system based on my findings.This assignment serves as an opportunity to establish a nurse-client interpersonal relationship that will help identify the patient’s individual needs and concerns to build a nursing diagnosis, care plan, interventions, and then evaluate results to treatment implementations. Date: November 29, 2011 Nurse: Karlyne Rubalcaba Patient: R.
M DOB: June 12, 1966 Civil Status: Married Birthplace: Havana City, CubaChief Complaint & ID: Ms. R is a 45 y/o WF who has been having chest pains for the last week. Source: patient, who is reliable Reason for Seeking Care: patient states “I came in today because I have pain in my chest and doesn’t let me breathe well” History of Present Illness: This is the first admission for this 56 year old woman, who states she was in her usual state of good health until one week prior to admission. At that time she noticed the abrupt onset (over a few seconds to a minute) of chest pain which she describes as dull and aching in character.The pain began in the left para-sternal area and radiated up to her neck.
The first episode of pain one week ago occurred when she was working in her garden in the middle of day. She states she had been working for approximately 45 minutes and began to feel tired before the onset of the pain. Her discomfort was accompanied by shortness of breath, but no sweating, nausea, or vomiting. The pain lasted approximately 5 to 10 minutes and resolved when she went inside and rested in a cool area. Since that initial pain one week ago she has had 2 additional episodes of pain, similar in quality and location to the first onset episode.
Three days ago she had a 15 minute episode of pain while walking her dog, which resolved with rest. This evening she had an episode of pain awaken her from sleep, lasting 30 minutes, which prompted her visit to Emergency Department. At no time has she attempted any specific measures to relieve her pain, other than rest. She describes no other associated symptoms during these episodes of pain, including dizziness, or palpitations.
She becomes short of breath during these episodes but describes no other exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea.No change in the pain with movement, no association with food, no GERD sx, no palpable pain. She has never been told she has heart problems, never had any chest pains before, does not have claudication. She was diagnosed with HTN 3 years ago.
She does not smoke nor does she have diabetes. She was diagnosed with hypertension 3 years ago and had a TAH with BSO 6 years ago. She is not on hormone replacement therapy.
There is a family history of premature CAD. She does not know her cholesterol level. ————————————————- ————————————————- Past Health HistoryChildhood Illnesses: chickenpox at age 7. No Measles, Croup, Whooping Cough (Pertussis), mumps. No Polio, Ear infections, Rheumatic fever, Scarlet fever, Impetigo, Kawasaki disease, Meningitis. Surgical: 1994: Total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids 1998: Bunionectomy Medical History: 1998: Diagnosed with hypertension and began on unknown medication. Stopped after 6 months because of drowsiness. 1990: Diagnosed with peptic ulcer disease, which resolved after three months on cimetidine.
She describes no history of cancer, lung disease or previous heart disease.Allergy: Penicillin; experienced rash and hives in 1985. Social History Alcohol use: 1 or 2 beers each weekend; 1 glass of wine once a week with dinner.
Tobacco use: None. Medications: No prescription or illegal drug use. Occasional OTC ibuprofen (Advil) for headache (QOD). Accidents or Injuries: No automobile accident.
Immunizations: Childhood immunizations up to date. Last influenza, “probably 2 years ago”. No TB skin test.
Last Examinations: Last examination 2 weeks ago, general check up, told “normal”. Yearly clinical breast examination (CBE), mammography, told “normal”.Yearly Pap smear, last performed January last year, 2010.
Last visit to oncologist, 2008, told “normal”. Current medications: Prescribed Antacids, Nexium, q24h, or when pain is severe, Tylenol 500 mg, PO, q12h. ————————————————- Family History R. M is the first youngest child, two sisters, healthy, parents married, father had chronic alcoholism, mother remains in perfect general health, not known disease or condition. Grandmother on father’s side T. E, died at age 78, from cardiac arrest; Grandfather on father’s side, R.
M, died at age 45, from automobile accident; Grandmother on mother’s side, L. S, suffered from Parkinson, died at age 79, from fall; Grandfather on mother’s side, I. A, no chronic disease that the patient recalls grandfather had, died at age 99, MI. None of them divorced. ————————————————- Review of Systems General Health: Reports usual health “Good”.
No recent weakness, fever, fatigue or malaise, weight change, present weight 190 Lbs, overweight. Patient reports acid gastric, mild pain and gasses at night. Not on a diet. Not physical activity, sedentary life.Skin, Hair, and Nails: No history of skin disease. Patient reports family history of allergies to penicillin, especially when skin comes in contact with dust.
No other allergies to drugs, plants, or animals were reported. No change in skin color, pigmentation, nevi, or mole. No pruritus, rash, itching, lesions. No bruises present. Denies any changes in medication or its dosages. Patient is allergic to penicillin react rash.
Hair, no loss (alopecia) or change in texture. No change in nails, their shape, color, brittleness. Patient denies chewing, biting nails.Patient denies environmental and occupational hazards, such as dyes, toxic chemicals, radiation.
Patient reports caring for her skin, hair, and nails by maintaining good hygiene, applying non-sun blocks creams and lotions to retain moister in skin. Patient clips her own cuticles on nails. Denies previous experience with dermatitis or herpes. Head, Face, and Neck, Including Regional Lymphatics: patient reports having severe, unilateral, throbbing, sometimes sharp, migraines episodes, occurring once a month, each lasting more than 3 hours. Episodes occur suddenly. First headache episode occurred at age 18.Patient pointed at area where it usually hurts, which is frontal area and behind eyes.
Patient stated “the pain creates tension or pulling sensation that takes over my neck”. Patient reports that when anxious, pain appears, provoking neck pain and stiffness, and nausea. No family history of migraines. Pain worsens when reading, feeling stressed, or preoccupied and is relieved by taking Benadryl, PO, 5 mg, q24h, along with Tylenol, 500 mg, q12h, and using water cold compresses. Patient states not missing ADL activities during episodes.
Patient denies head injury, any head trauma, or loss of consciousness.Denies dizziness or lightheaded, syncope, or vertigo. Patient reports acute onset of neck stiffness and pain with headache. Patient reports limited range of motion when trying to turn head.
Patient is able to do her work but not to sleep. Takes medications and changes positions of pillows to help with the sleep. No lumps or swelling reported. Patient reports no Dysphagia. No history of neck surgery. Patient had neck surgical removal of occipital and posterior cervical cancerous lymph nodes.
Eyes: Patient reports difficulty seeing or staring closely at an object, computer screen, or small letters.Patient wears glasses. Patient reports progressive blurry vision bilaterally when not wearing glasses. Patient denies eye pain. No strabismus, diplopia, redness, or swelling. No past history of eye infections, watering, discharge, glaucoma, surgery, or injury. Patient reports history of allergies. Pollen, humidity, or dust causes her irritation of conjunctiva.
Irritation gets relieved by washing eyes thoroughly. Last visit to ophthalmologist 1 ? year ago, “told normal”. Patient was encouraged to keep practicing self-care behaviors as usual. Patient does not recall exact vision measurements.Ears: Patient denies hearing loss or difficulty.
No earaches, infections now or as child, no history of OM, no discharge, tinnitus, or vertigo. Self-care appropriate. No exposure to environmental noise. Clears ears with cotton swaps every 15 days. Nose: Patient reports continuous, watery, runny nose (rhinorrhea), occurring during allergic reaction to dust, environmental changes, and pollen. Has two colds yearly. Patient denies sinus pain, or current nasal obstruction, unless having a cold.
Never suffered trauma. No epistaxis (nosebleeds). Client reassures having seasonal and allergen agent allergies.No change or decrease in sense of smell reported. Mouth and Throat: Patient denies current lesions and sores in mouth, tongue, and gums. Patient recalls sores in the past due to gastric acid reflux (heartburns). No report of altered taste. Denies alcohol consumption.
Reports past history of smoking cigarettes, from age 17 to age 33, when she quit, one pack a day. No caries, tooth loss, or periodontal diseases reported. Brushes teeth after every meal, uses mouthwash, flosses twice daily. Patient does not wear bridges, headgear, or dentures. Neck: No pain, lumps, or swollen glands to palpation.ROM not limited. Breast and Regional Lymphatics: Patient denies pain (mastalgia), lumps, she states “I haven’t noticed any lump or mass that I recall”, no discharge from nipple, rash, swelling, trauma, injury. Patient reports surgery on breasts, mammoplasty to reduce and lift breasts.
Client reports last BSE two years ago, stopped because did not think it was necessary a yearly examination. Patient did last mammography and x-rays in 2010. Patient denies any change in breast contour, size, firmness. Patient does assures having decreased estrogen levels although no shrinkage is apparent.No history of breast disease in self, mother, or grandmothers.
Thorax and Lungs: Patient reports having sudden, unusual morning coughs, always nonproductive. Patient denies blood with the cough (hemoptysis); sputum has no odor, mucus is clear, and congested cough. Cough gets relieved by drinking glass of water. Patient reports shortness of breath when taking more than 10 stairs up, lasting for a few second, less than a minute. No family history of lung disease.
Patient denies orthopnea, paroxysmal nocturnal dyspnea. No history of Asthma. No cyanosis or diaphoresis.Patient denies chest pain during breathing. Past history of mild emphysema, no wheezing reported. Patient reports she smoked, starting at age 17 until age 33, 1 PPD, quit 16 years ago. Denies leaving with someone who smokes.
Works in a pharmacy, no exposure to environmental, chemical hazards. Last influenza immunization 2 years ago. Heart and Neck Vessels: Patient denies chest pain (angina), tightness, diaphoresis, palpations, tachycardia, fatigue, cyanosis, pallor, cold sweets, nausea, dyspnia, paroxysmal nocturnal dyspnia, orthopnea, nocturia, or edema.Patient reports sleeping with two pillows. No history of CAD, anemia, Hypertension, or heart murmur.
Gastrointestinal: Patient reports good appetite with no changes. No Dysphagia reported. Patient states having food intolerance (when eats tomatoes, eggs, or drinks citric juices). Patient reports Pyrosis (heartburn) constant eructation after heavy meals. Patient takes antacids (Nexium, prescribed, 500 mg/cap) 30 minutes before eating strongest meal during the day to relieve discomfort. No abdominal pain, nausea, vomiting, hematemesis, or history of food poisoning reported.No history of ulcers, liver, or gallbladder disease, no jaundice, appendicitis, or colitis. Bowel movement twice daily, brown, consistency is firm and pasty sometimes.
Patient denies diarrhea, constipation, use of laxatives, no presence of Melena (occult blood) bleeding, no history of hepatitis. Hormonal changes reported due to menopause. Peripheral Vascular: Patient reports burning pain down the right leg when lifting, pushing against, and moving heavy objects. Pain is reported to appear sudden at first but worsening when bending the back or if remaining sited for long periods of time.Alleviated only by medications (Tylenol, PO, 500 mg, q12h) or by switching positions. Patient denies trying other methods to help relief pain. Sedentary lifestyle. Obesity.
Patient denies history of vascular problems, heart disease, diabetes. Patient does not currently smokes, but has past history of smoking. Denies skin changes on arms and legs, no coolness, leg ulcers, edema, various veins, or infections. Legs equal in length. No lymph node enlargement, or lumps reported. Patient not taking oral contraceptives or hormonal replacement. Patient works as Pharmacist, standing for more than 8 hours/day.
Female Genitourinary: Patient reports first menstrual period (Menarche) at age 12, irregular throughout young adulthood; Last menstrual period at age 39, sudden cessation caused by chemotherapy cancer treatment. Patient describes LMP as few, pink spots, lasted two days. Patient reports history of Menorrhagia, clotting, and severe lower abdominal cramps and pain.
Grav-3; Para-1; AB (miscarriages) 2. Reports no feelings of loss regarding early menopause. Patient denies dysuria, frequency, urgency, nocturia, hematuria, bile in urine, UTI, incontinence, dyspareunia, hesitancy, or straining.
No pain in flank, groin, or suprapubic region. Urine color yellow. No history of kidney disease. Patient denies past history of problems in genital area, sores, lesions, but does reports Cesarean surgery performed at age 24 to give birth. States sexual relationship and satisfaction as “not satisfied”. Patients reports being married for 31 years now and not enjoying sexual activities, feels unsatisfied, and lack of communication with partner during intercourse. No STDs. Musculoskeletal: Patient denies joint pain, general stiffness, swelling, redness, heat, Myalgia, atrophy, or weakness.
No history of Rheumatoid Arthritis. Patient reports decreased ROM when bending forward. No history of fractures, bone pain, no congenital deformities, accidents or trauma that could have affected joints, no reports of dislocations, sprains, strains, numbness, or tingling. Patient reports severe back pain, lower back, pain shooting down leg. No history of arthritis, gout. Patient does not exercise.
Reports limitations on ADLs when bending, cleaning up the house, or walking up the stairs. No self-esteem disturbed, no body image affected. Role performance affected.Neurologic: Patient denies history of seizure disorders, stroke, or fainting. Denies alcohol use or street drugs use. No weakness, tremor, paralysis, problems with coordination, Dysphagia, Dysarthria, or Dysmetria. No numbness.
Patient denies memory problems, nervousness or mood change, or depression. Anus and Rectum: Patient reports no hemorrhoids or discomfort, no anal fissures, or lesions. Rectal wall intact, no masses or tenderness reported. Patient reports stool soft, brown, firm sometimes. ————————————————- Functional AssessmentSelf-Concept: Patient is a graduated Accountant and Pharmacist. Currently working as Pharmacist. Has never been unemployed.
Perceives herself as blissful full-time mother, wife, and a good daughter and loving sister. Lives with daughter and husband. Patient denies religion preference during childhood; At age 37 converted from no belief or religion to Christianity, attends church during the week and on Sunday mornings.
Patient believes self to be honest, independent, hard worker. Does not smoke, drink alcohol. Considers weight as limitation, willingness to improve and loss weight.No body image disturbances or self-esteem problems. Activity-Exercise: During a typical day patient: wakes up at 7:30 am, gets ready to go to work, has breakfast, leaves house at 8:00 am, starts working at 9:00 am, has lunch at 2:00 pm or 3:00 pm for a whole hour, goes back to work around 3:30 pm, ends shift at 6:00 pm, returns back home at 7:00 pm, takes a shower to release tension from work, around 7:00 pm cooks meals for next day’s lunch and dinner to her family, eats a snack or serves herself a cup of hot milk, watches TV, goes to sleep at 11:00 pm.
Believes self able to perform most ADLs; No problems in bathing, dressing, cooking, driving automobile; difficulty performing household tasks requiring bending or lifting. Hobbies are reading a suspense book, baking, visiting friends, watching movies. Sleep-Rest: Bedtime at 11:00 pm. Sleeps 8 hours. No sleep aids. Nutrition: 24-hour recall: Breakfast: cup of coffee; Lunch: Carbohydrates, like pasta, rice, protein, like steak, chicken breast, salmon, vegetables, legumes, fruits, like bananas, yogurt, regular; dinner: none, coffee, cup of milk.Eats dinner with family only when it goes out, especially on Sundays.
Once in a while, eats at fast-food restaurant. Shares cooking shores with daughter. Food intolerance: when eats tomatoes sauce, potatoes, eggs, citric juices. Alcohol or Drugs: Patient denies alcohol or any drugs consumptions. Denies smoking, patient quit years ago. Noone else in family smokes. Interpersonal Relationships: Describes family life growing up as “normal enough” although parents divorced when patient was a child.
No abusive behaviors on mother or father’s side.Parents divorced because of lack of communication and alcoholic father. Has an excellent relationship with brother who currently lives in Spain and with mother who lives in Cuba.
Reports that loves husband and have respectful relationship. Friends: 2 women. Is always with daughter and are very close. Coping and Stress Management: Patient believes neighborhood safe. Home has no safety hazards.
Uses relaxations techniques like deep breathing to release tension from stress of work. Reports financial worries. ————————————————- Perception of HealthPatient perceives health and illness as normal life processes, “I see things different and set priorities in a more practical way since I suffered from cancer, now I value what is really important”. Believes life is easier guided and enjoyed when: “if God is present, even if things end up wrong, there’s something good to learn that serves for future experiences and decisions”. Patient smiles with no further comments.
————————————————- Measurement Height: 163 cm (5’4”) Weight: 220 lb B/P: 120/78right arm, sitting; 110/75 right arm, lying; 110/ 70 left arm, lying Temp: 37?C Pulse Rate: 88, regular Respiratory Rate: 14, unlabored ————————————————- Head-to-Toe Examination Skin, Hair, Nails: I inspected skin color. Skin pigmentation looks even, expected darker pigmentation on sun-exposed areas (face, forearms, neck), multiple nevi with no change in symmetry, border, color, diameter or elevation. Patient has no significant birthmarks or widespread color change. No pallor, erythema, cyanosis, or jaundice present.
I noted temperature of patient’s hands, palpated them and checked bilaterally. Skin is warm bilaterally.No signs or symptoms of hypothermia or hyperthermia.
Perspiration appears normally on face, hands, axilla, skinfolds. No Diaphoresis present. Oral mucous membranes look smooth and moist, generally hydrated. Skin texture feels smooth and firm with even surface, no signs or symptoms of hypothyroidism and hyperthyroidism present. Epidermis looks uniformly thin in most of the body, few (2) calluses present on right sole of foot, one single callus on left sole. No edema present. I pinched up a large fold of skin on anterior chest under clavicle.
Skin’s turgor was normal as well as its mobility, showing proper hydration and elasticity.No bruising, vascularity, or traumatic lesions present. Silvery elevated straie present on pelvic area, hips, bilaterally, and lateral lower back. Scars present less than 6 cm long and less than 4 mm wide. Normal distribution and texture of hair, no pest inhabitants. Fine vellus hair coating body while coarse hair at the eyebrows, eyelashes, and scalp. Distribution conforms to normal female patterns. Normal curved nail surface present, 160 degrees.
Surface feels smooth, regular, not brittle or splitting. Thickness is uniform. Nail firmly adherent to nail bed and base firm to palpation present.No cyanosis or pallor present. Pink nail bed reflected underneath. I performed the capillary refill test and results were normal, color return took less than 2 seconds.
Head, Face, and Neck, Including Regional Lymphatics: Normocephalic head, no deformities, no lesions, or lumps. Facial structures look symmetric, with symmetric eyebrows, nasolabial folds, and sides of mouth. No swellings, no involuntary facial movements. Facial expressions appropriate to mood during conversation. Facial hair even. No abnormal changes in skin tone.
No current limitation of movement during active motion.I asked the person to touch her chin to the chest and turn head to both sides right and left while trying to touch the ears to the shoulder and extend head backward. Motion is smooth and controlled. Head centered midline.
Appropriate muscle strength and normal cranial nerve XI status. No obvious pulsations present. I palpated the neck lymph nodes, salivary glands not palpable. No abnormal enlargements. Scar in neck present from surgical removal of posterior cervical cancerous nodes.
Thyroid not palpable and moves up and down freely when swallowing. Nodes feel movable, discrete, soft, and nontender.Eyes: After performing the Snellen Eye Chart exam on patient, placing her 20 feet from chart, patient hesitated while reading down the chart.
Patient leaned forward but did not misread letters. Presbyopia present. OD: 20/150; OS: 20/200 without glasses. Peripheral vision fields intact. Bilateral symmetric cornea reflex present. Eyes look symmetric.
Closure of eyelids normal. No phoria, tropia, weakness of extraocular muscle (EOM) present. Parallel eye movement tracking bilaterally. No nystagmus. No lid lag. Eyebrows present bilaterally, move symmetrically with facial expressions.
No lesions. No exophthalmos or enophthalmos eyes present. No cyanosis or pallor of lower lids. No scars on eyes. Sclera looks white and moist. No discharge, lesions, foreign object.
Lacrimal glands look intact with no swelling or tenderness. Cornea appears clear, smooth, not opaque. Iris appears flat, with round, regular shape, coloration is even. PERRLA or (Pupils Equal Round Reactive to Light and Accommodation) test intact. No anisocoria of pupils present.
No signs or symptoms of cataracts present. Vessels appear normal, could not distinguish quadrants, diameter, or dark spot.Ears: No masses, lesions, scaling, discharge, tenderness present during palpation of pinna and auricle. External ear canal clear, with no foreign object, discharge, no otorrhea, polyps, furuncle, crusts, exostosis, microta, or macrotia present.
Tympanic membrane pearly gray, appears intact without perforations. Whispered voice test was performed on patient and patient was able to repeat words correctly. Weber test performed, patient was able to hear tone by bone conduction through skull bilaterally. Rinner test performed, AC>BC bilaterally. Nose: I inspected and palpated the external nose first.Nares are symmetrical, midline septum, no septal deviation, in proportion with other facial features.
No deformities, pain, or tenderness to palpation. Nares are patent with no obstructions like (polyps, rhinitis, common cold), no perforation. No sinus tenderness. Mucosa looks pink, no lesions. Absence of epistaxis.
During transillumination, an observable diffused red glow was present. Mouth and Throat: Mucosa and lips with no cracking (cheilitis), absence of Herpes Simplex and other lesions. Mucosa looks moistened and has pink color. No bleeding gums.
No missing teeth.Few dark spots on teeth. No malocclusion. Tongue symmetric, protrudes midline, no tremor. Pharynx pink, no exudates. Uvula rises midline on phonation. Tonsils 1+. Gag reflex present.
Neck: Neck with full range of motion (ROM), no head tilt. Symmetric, no masses, tenderness,Salivary glands not palpable. No lymphadenopathy, nodes feel movable, discrete, soft, and nontender. Thyroid gland nonpalpable, not tender. Trachea midline. Carotid arteries 2+ palpated, equal bilaterally, no bruits found during auscultation.
Internal Jugular pulse not palpable, flat at 45 degrees.Breasts and Regional Lymphatics: During inspection of breasts, symmetry of size and shape observable. Contour and consistency firm and homogeneous. Skin looks smooth with even color.
No redness, bulging, dimpling, skin retraction, discharge, lesion, dilated superficial veins, striae, scaling, or fixation present. Tender, enlarged lymph nodes absent. No induration or subareolar mass present. Thorax and Lungs: Shape and configuration of chest wall without presence of scoliosis, kyphosis, or signs of Barrel chest; not easily observable due to thick tissue in abdominal area. Symmetric thorax.Spinous processes appear in straight line. Patient acquired relaxed posture during examination. Skin color and condition consistent with generic background.
No cyanosis, pallor, lesions, changes in nevi present during inspection. Symmetric chest expansion to palpation. Tactile fremitus prominent between scapulae and palpable through vibration. No signs of consolidation. No pneumonia, rhonchal, pleural, increased, or decreased fremitus. Crepitus absent. Skin feels moisture, smooth, warm, with no lumps or masses noted during inspection and palpation.
Predominant resonance, low-pitched, clear, hollow sound over lungs to percussion.No hyperresonance or dullness. Normal breath sounds; bronchial breaths short during inspiration, large with expiration; bronchovesicular sounds, both inspiration and expiration, equal duration; vesicular sounds long during inspiration, short with expiration. No crackles, rales, or wheezing present. No presence of bronchophony, egophony, and pectoriloquy.
Same results while assessing anterior chest wall. Heart and Neck Vessels: Normal carotid pulse strength 2+, no bruits present, no abnormal pulsations, no distention of external jugular veins observable during inspection while positioning patient supine.Apical pulse at 5th intercostals space, left midclavicular line, no thrills. S1, louder than S2 at the apex; S2 heard louder than S1 at the base. It coinsides with carotid artery pulse. No S3 or S4 present. No murmurs, no systolic murmur. Gastrointestinal: Abdomen is flat and symmetric, with no scaphoid, or protuberance, no abdominal distention, bulges, masses, hernia, or ascites.
Umbilicus is midline, inverted, no signs of discoloration, inflammation, no redness. Skin looks and feels smooth, with no lesions, scars, or rashes.Observable silvery striae, less than 5 cm long, located in lower back, hips, and pelvic area. No prominent, dilated veins, not observable veins. Good skin turgor reflecting hydration and proper nutrition. Pubic hair distribution normal, inverted triangle shape. No aortic pulsations observables. Not signs of restlessness during examination.
No endocrine abnormalities in the present. No chronic liver disease. Bowel sounds present, no bruits. Tympanic sounds predominate in all quadrants. Liver spam 8 cm in right midclavicular area. Abdomen soft, no organomegaly, masses, tenderness, and no inguinal lymphadenopathy.Peripheral Vascular: During inspection, skin color appropriate according to heritage background, no presence of cyanosis on skin and nail beds, hands’ temperature warm to palpation, texture smooth, and good skin turgor; No lesions, edema, or clubbing, normal nail bed angle (160 degrees).
Capillary refill about 2 seconds. Upper extremities symmetric in size. No needle tracks found or any other scars. Presence of 3+ left radial pulse, 2+ right radial pulse. Ulnar pulse unable to palpate bilaterally. Epitrochlear node absent to palpation. Modified Allen test performed, adequate circulatory return and normal hand’s color within 5 seconds.
No presence of skin discoloration or skin ulcers in lower extremities. Homans’ sign negative. No enlarged, fixed, tender nodes in femoral area. Popliteal and Posterior Tibial pulses unable to localize and palpate. Dorsalis Pedis pulse patent.
No signs of pitting edema, varicosities, elevational pallor. No sensory or motor loss in lower extremities. Female Genitourinary: External genitalia has no lesions, rashes, discharge. Bimanual internal genitalia examination not performed. Hair well distributed.
Labia majora symmetric, plump, well developed. Clitoris present. Labia minora looks darker, moist, and symmetric.Vaginal opening appears as vertical, large slit. Perineum is dry. Musculoskeletal: Temporomandibular joint with no slipping or crepitation. Full ROM in neck with no pain. Tenderness in vertebral column and stiffness or pulling sensation in muscles of lower back, no deformity or curvature.
Impaired extension and lateral bending, but full lateral rotation present. Arms are symmetric, extremities have full ROM. Not full ROM in right lower extremity, hip flexion with knee straight 45 degrees and hip flexion with flexed knee 90 degrees. No pain. Unable to maintain flexionagainst resistance for extended periods.Neurologic: Mental status, appearance, behavior, speech is appropriate. Patient is alert and oriented to person, place, and time.
Thought processes coherent. Remote and recent memories are intact. Cranial nerves II through XII are intact. Sensations of light touch and vibration are intact. No atrophy, weakness, or tremors present. Gait affected by right lower extremity limping.
Anus, Rectum: No lesions in perianal area. Sphincter tone well. Rectal wall smooth, no mass, tenderness, or inflammation. Anal opening tightly closed.
No anal discoloration, normal pigmentation present.