The patient is an 87 year old Caucasian female who is lying in bed and in no apparent distress. She is alert,
cooperative, has a relaxed facial expression, and appears to be her stated age.
Blood pressure (BP), 186/72 right arm (supine), 180/78 left arm (supine), 176/82 left arm (sitting); unable to
obtain BP with pt standing; radial pulse right and left 70 and regular; respirations 20 and regular.
Skull and face symmetrical with no palpable masses, lesions, or areas of tenderness in hair or scalp. Hair white,
clean, fine-textured. Skin on face warm, dry, and slightly tanned with a one cm round brown spot on left
forehead and a ½ cm round brown spot on right ear lobe. Facial sensation intact to pin and cotton. Smiles,
grimaces, wrinkles forehead, and closes eyelids tightly. Clenches jaw without pain.
Symmetrical with no drooping, tumors, crusting, or edema of eyelids. Conjunctivae are pink, sclera are white,
iris is blue, cornea appears clear. Visual acuity with corrective lenses using near card: right eye (OD) 20/70, left
eye (OS) 20/30; visual fields grossly intact by confrontation; Extraocular movements (EOMs) intact; eyes in
alignment. Pupils are equal, round, and reactive to light, and accommodation (PERRLA). Opthalmoscopic
examination: red reflex present; retinal vessels prominent; unable to visualize optic disc or macula.
No maxillary or frontal sinus tenderness on palpation or percussion. Nostrils patent bilaterally. Nasal septum
without lesions or signs of erosion; mucosa pink with scant clear discharge; nonswollen turbinates.
External ears symmetrical without lesions or tenderness; external canals normal. Whisper test positive for
hearing loss in both right and left ears. On Weber test, no lateralization; on Rinne test, air condition greater
than bone conduction (AC>BC) bilaterally. Small amount of reddish cerumen in ear canals. Tympanic
membranes pearly gray; light reflexes and landmarks appropriately placed bilaterally.
Twenty-six discolored teeth with numerous fillings; food particles between teeth. Tongue and uvula midline;
gingivae normal - without bleeding; lips pink; musoca, tongue, palate, and throat pink with no petechiae,
ulcerations, masses, or exudate. No signs or malignancies. Gag reflex present bilaterally. Tonsils absent.
Tongue pushes easily against resistance of tongue depressor.
Full range of motion (ROM) of neck with equal, bilateral strength to resistance. Nonpalpable occipital,
postauricular, preauricular, tonsillar, submaxillary, submental, posterior cervical, anterior cervical,
supraclavicular, and infraclavicular lymph nodes. Trachea midline and mobile. Carotid pulses bilaterally full
and equal; no bruits. Jugular veins visible while patient in supine position, and flat while patient sitting upright.
Mild kyphoscoliosis present. Anteroposterior diameter 1:2. Respiratory expansion equal; diaphragmatic
excursion 5 cm bilaterally; normal tactile fremitus bilaterally; breath sounds clear but diminished in all fields.
No costovertebral angle tenderness. Nail beds pink; no clubbing of nails.
Left breast slightly smaller than right (has been this way since puberty). No skin changes, tenderness, lumps or
masses, nipple discharge, or axillary or epitrochlear adenopathy. Does not perform breast self-examination.
No lateral displacement of PMI. Point of maximum impulse (PMI) fifth intercostal space, midclavicular line
(5ICS-MCL); no thrills or heaves palpated. Auscultation reveals a Grade III systolic murmur heard best in the
mitral area. S1 and S2, regular rate and rhythm.
Abdomen soft. Contour of abdomen flat without lesions or pulsations. No scars, striae, inguinal, or femoral
hernias visible. Bowel sounds auscultated in all four quadrants. Femoral pulses equal bilaterally. No aortic,
renal, iliac, or femoral bruits. No masses, tenderness, hepatomegaly, or splenomegaly. Tympany throughout
abdomen on percussion. Liver span of 6 cm percussed at right midclavicular line. No hepatic tenderness or
rebound tenderness.
No malignant changes, pressure sores, evidence of pruritus, or ecchymoses of skin in back or sacral area.
Dorsalis pedis and posterior tibial pulses are of normal amplitude and equal bilaterally.
No edema of feet or ankles. Normal hair distribution on feet and toes.
Oriented to person, place, and time; able to count backwards by 7; recent memory intact
as evidenced by patient recalling 3 words she had been previously asked to recall;
reasoning intact and judgment appropriate as evidence by patient’s ability to problem
solve in a hypothetical situation; cranial nerves II-XII intact (cranial nerve I not tested);
Deep tendon reflexes: brachioradialis, biceps, and triceps 2+ and equal; patellar and
Achilles reflexes 1+ and equal. Plantar reflex intact. Sensory function intact to pin and
cotton over fingers, hands, toes, and feet bilaterally. Vibration sense, proprioception, and
two point discrimination intact bilaterally in hands and feet. Romberg and gait not tested.
No joint deformities are noted. Range of motion of hands and wrists are normal
bilaterally; however, patient reports pain with hand and wrist movement. There is a
marked reduction of flexion and extension of the left knee and marked reduction of
internal and external rotation of the hip. Range of motion of the spine was not tested.
Muscle size in upper extremities equal bilaterally. Hand grasps strong and equal
bilaterally. Muscle size in lower extremities equal bilaterally; muscle strength in lower
extremities unequal bilaterally. Marked weakness in quadriceps muscle of left leg and in
dorsiflexion of left ankle.
Muscle strain and weakness left lower extremity.
Left leg and lower back pain.
Arthritic joint pain - especially in hands and wrists.
Systolic hypertension managed with medications.
Congestive heart failure and pulmonary edema managed with medications.
Potential for hypokalemia related to diuretic therapy.
History of thrombophlebitis in both legs.
Bilateral hearing loss.
Limited vision in R eye. Needs thorough ophthalmologic examination.
Poor dental hygiene.
Potential for inadequate nutrition related to anorexia, nausea, and food intolerance.
Potential for inadequate elimination related to constipation.
Potential for sleep deprivation related to sleeping poorly during the night.
Activity intolerance related to left lower extremity pain and weakness.
Self care deficit related to left lower extremity pain and weakness.
Potential for injury related to “feeling faint” when arising from a supine position and
left sided weakness and imbalance.
17. Potential for ineffective home management related to pts inability to care for self and
advanced age of husband.
18. Potential for depression related to loss of independence and slow recovery from LLE
musculoskeletal strain.
19. Does not perform regular breast self-examination.