SAMPLE PHYSICAL EXAMINATION GENERAL APPEARANCE 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. VITAL SIGNS 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. HEAD AND FACE 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. EYES 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. NOSE 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. EARS 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. MOUTH 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. NECK 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. CHEST AND RESPIRATORY 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. FEMALE BREAST 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. HEART 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 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. BACK AND SACRUM No malignant changes, pressure sores, evidence of pruritus, or ecchymoses of skin in back or sacral area. PULSES 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. NEUROLOGIC 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. MUSCULOSELETAL 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. PROBLEM LIST FOR PATIENT 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 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.