PHYSICAL EXAMINATION: General: The patient is morbidly obese, lying comfortably in the bed, in no apparent distress. Vital Signs: Blood pressure 112/56, pulse rate 62 per minute, respiratory rate 17 per minute, and pulse oximetry 93% on room air. She is afebrile. HEENT: Pupils are equally round and reactive to light and accommodation. Extraocular movements are intact. Sclerae anicteric. No oropharyngeal congestion. Neck: Supple. No JVD bilaterally. Carotids are 2+. No bruits. No thyromegaly or lymphadenopathy. Chest: Clear to auscultation and percussion. Cardiovascular System: S1 and S2 normal. No S3, S4, murmurs, rubs, or gallops. Apical impulse is nondisplaced. Abdomen: Soft, nontender with no organomegaly. Bowel sounds are present and are normal. No pulsatile masses or bruits. Extremities: No pedal edema, cyanosis, or clubbing. Neurological: Grossly nonfocal. Skin: No rashes. Musculoskeletal: No joint swelling or tenderness.
PHYSICAL EXAMINATION: General: The patient is in no acute distress. Vital Signs: The temperature is 98.8 degrees, heart rate is 106, respiratory rate is 21 and blood pressure is 122/72. HEENT: Anicteric sclerae. Pupils reactive to light. Neck: Supple without lymphadenopathy. Lungs: Clear to auscultation and percussion. Heart: Regular and rhythmic. No murmurs. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly is present. Extremities: No edema. Distal pulses are symmetric. Neurologic: Exam is nonfocal. Skin: Examined, erythema and edema on the proximal knee and an extension of 30 cm in that area with a furuncle that is exudating old blood mixed with pus. There is also a superficial lesion on the right hand that measures 0.2 cm in diameter. It is unroofed and cultured.
PHYSICAL EXAMINATION: General: Awake, alert, but not oriented to the situation. He, however, can state and confirm the site of the tenderness in his abdominal wall. Vital Signs: His temperature is 97.7 degrees Fahrenheit, heart rate is 62 per minutes, respirations 22 per minute, blood pressure 172/75 mmHg. HEENT: Head is normocephalic. Pupils are round and reactive to light and accommodation. The patient has redness of the conjuctivae. Sclerae are anicteric. Lungs: Clear to auscultation bilaterally. Heart: Tones are distant. Heart rate is regular. No murmur heard. Abdomen: Distended. Hyperkinetic bowel sounds are present. Abdomen is distended in the right lower quadrant, but there is no rebound tenderness or muscular guarding. Liver and spleen are not palpable. The patient's abdomen is obese. Skin: Pale or dry. Extremities: He is able to move all four extremities. Strength is 5/5.
PHYSICAL EXAMINATION: General: Cachetic-appearing male who appears to be in no acute distress. Voice: Weak and breathy with good communication ability in the hospital room setting. Head and Face: Normocephalic. Nontender over the paranasal sinuses to percussion. Salivary glands are normal on palpation. Facial strength is symmetrical on inspection. Ears: Canals, TMs, and middle ear are all unremarkable otoscopically. Hearing acuity is grossly intact. Nose: The patient does have nasal prong oxygen in place. There is no sign of clot, discharge, ulceration or lesion within the right naris. The patient does have some dried, crusted blood on the left side of the septum, and the mucosa is somewhat friable anterior to this. It bleeds easily with touch. This was controlled with silver nitrate cautery. In general, the nasal mucosa is congested on the left side. Clear mucoid drainage is noted. No overtly purulent secretions are seen. Mouth and Pharynx: Edentulous. No oral or pharyngeal lesions, inflammation or exudative findings. Hypopharynx, Larynx, and Tongue Base: Without lesions on indirect inspection. Has incomplete glottic closure due to generalized weakness. He does exhibit some pooling of secretions. Neck: Without tenderness, mass, lymphadenopathy, thyromegaly or nodules.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 112/78, pulse 86 and regular, respirations 18, temperature 99.4 degrees, and oxygen saturation 98% on room air. GENERAL: This is a well-developed, well-nourished female who appears to be in no acute distress at this time with a GCS of 15. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Extraocular muscles are intact. Conjunctivae are pink. Mucous membranes are moist. Oropharynx is clear. Nasopharynx is clear. There is no hemotympanum, Battle's or raccoons. Maxilla, mandibles, zygoma, and orbits are nontender and intact. NECK: Collared. Trachea is midline. There is no JVD, stridor, subcutaneous crepitus. There is diffuse vertebral process tenderness with no bony step-off appreciated. CHEST: The patient does have tenderness to palpation in the area of the left posterolateral chest wall with no visible lesion noted. No bony step-off noted. No flail segment noted and no subcutaneous crepitus noted. There is noted to be symmetric rise and fall of the chest wall. LUNGS: Bilaterally clear to auscultation. HEART: Regular rate and rhythm with no ectopy. Heart rates in the 70s. BACK: Exam with C-spine immobilization. There is diffuse vertebral process tenderness from T1 to S1 with no bony step-off appreciated as well as some left paraspinal lumbar muscle tenderness. No spasm is appreciated. No visible lesion is noted. No CVA tenderness or scapular tenderness is noted. ABDOMEN: Soft, nontender, nondistended. PELVIS: Nontender and stable to rock. EXTREMITIES: All extremities are nontender. Neurovascularly intact with full range of motion. No visible lesions or deformities, except for the left upper extremity where the patient was noted to have diffuse tenderness to palpation involving the area of the left shoulder, the dorsal aspect of the left humerus, the left wrist including snuffbox tenderness. Of note, no visible lesions are appreciated. No soft tissue swelling is noted. There is noted to be full range of motion at all joints and extremities neurovascularly intact. NEUROLOGIC: The patient is awake and oriented x3, moving all extremities with no obvious focal or neurologic deficits. SKIN: Warm and dry.
PHYSICAL EXAMINATION: The patient appears his stated age. He had no aphasia or dysarthria. His pupils are equal, round, and reactive to light and accommodation. His visual fields are full. He had free range of motion to the extraocular muscles. Uvula, tongue, and palate move centrally and symmetrically. He had no evidence of facial weakness or sensory loss. His motor power was 5/5 in all four extremities. Deep tendon reflexes were 2+. Sensation was equal and symmetric. Stance and gait are normal.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure 144/72, pulse 106, respiratory rate 18, and O2 saturation 100% on room air. Pain score is 9/10, leg pain. The patient is pleasant and cooperative. Her mood and affect are appropriate. She is alert and oriented x3. Her language is fluent. Cognitive exam is normal and she gives a good account of recent and remote events. Cranial nerves II through XII are intact with no nystagmus. Visual fields are full to confrontation. Fundi are poorly visualized. She has a strong gag reflex. Cardiac exam is normal with regular rate and rhythm. Motor Exam: She has increased tone in her left arm and leg. She has left hemiparesis with strength approximately 4/5 in her left upper extremity. She is weaker in her left leg with strength approximately 3+ to 4-/5, being weakest in hip flexion and ankle dorsiflexion. Overall, her motor exam is unchanged compared with previous. On sensory exam, she has left hemisensory loss; although, this is mild. She also has decreased pinprick sensation in a stocking distribution, which is chronic. Vibration sense is decreased in her lower extremities, left greater than right. Deep tendon reflexes are brisk throughout. Coordination is slow bilaterally, more so on the left with mild dysmetria. Gait: She has slightly delayed postural reflexes. She has a spastic quality to her gait. She has left footdrop with circumduction of her left leg. She was steady, ambulating with her quad cane. on musculoskeletal exam, she has mild tenderness in her right lumbosacral and hip region.
PHYSICAL EXAMINATION: The patient is alert and oriented x3, in no acute distress, sitting comfortably on the examining table. His pupils were equal, round and reactive to light and accommodation. Pharynx is hyperemic, but no JVD, no LAD. Thyroid was normal. Lungs: Clear on auscultation bilaterally. Heart: Regular rate and rhythm with no murmurs. There is no pain that can be provoked by pressure on the ribs or the rib spaces, and there is no provocation on any pressure from right side of the chest wall and the abdomen. While lying down, the abdomen is obese. Bowel sounds are present. There is no splenomegaly. There are some signs of left liver lobe enlargement with some pain that can be provoked on deep palpation and there is the severity of the pain that the patient already described. There is mild pain in epigastrium that can be provoked on superficial and deep palpation. The rest of the liver does not seem to be enlarged and there is some pain that can be provoked on deep inspiration during the liver palpation. There is no sign of ascites or tumor masses. There are no signs of clubbing or cyanosis in extremities.
PHYSICAL EXAMINATION: On examination, height is 5 feet 4 inches, weight is 142, blood pressure is 132/72. Pain score 0/10. Head and neck exam is benign with no adenopathy appreciated. Scar from thyroidectomy is unchanged. There is no cervical adenopathy. Breast exam was performed in both the sitting and supine position with no skin change, mass or regional lymphadenopathy. There is slight inversion in the left nipple, unchanged from prior exams. There is no regional lymphadenopathy. There is no skin change or mass within the breast tissue. Respiratory: Clear. Abdomen is soft, nontender, with no hepatosplenomegaly. There is no palpable abdominal mass. There is no inguinal adenopathy. Pelvic: Normal female external genitalia. There remains some hypopigmentation on the posterior perineum and perianal skin suggestive of lichen sclerosus. The vaginal mucosa is atrophic. The cervix is multiparous with no significant prolapse. The uterus is small and anteverted in size. The ovaries are not palpable. Rectovaginal septum is normal. Extremities show no edema. Pap smear and HPV DNA test for high-risk viral types was obtained.
PHYSICAL EXAMINATION: The pain score is 2/10 in the small joints of the hands. Gait is stable and steady. The patient is a middle-aged, thin female, in no apparent distress. HEENT: Unremarkable. The neck is supple without lymphadenopathy. Heart is regular. No extra heart sounds. Lungs are clear. Abdomen: Positive bowel sounds. Skin: No active rashes or edema at this time; although, she does have evidence of some Raynaud's in the feet at this time. There is no specific soft tissue swelling. Her lung exam does not disclose a loud P2 component. She has no elevated JVP. Neurologic exam is grossly nonfocal. Skin shows no sclerodactyly, tendon friction rubs. She has otherwise normal digital pulp. No calcinosis. Previous nailfold capillaroscopy shows a few areas of dropout with dilatation. Her musculoskeletal exam shows no active synovitis, small or large joints. She does have a positive Finkelstein maneuver on the right thumb consistent with de Quervain's tenosynovitis or bony hypertrophic changes noted over several IP joints of the toes, but no dactylitis. No tendinopathy appreciated.
PHYSICAL EXAMINATION: The patient is a well-nourished, well-developed female in no distress. Blood pressure 134/70, pulse 84, oxygen saturation 96%, weight 182 pounds. The neck circumference is 17 inches. HEENT: Pupils are equally round and reactive to light. Nasal mucosa is mildly congested. No sinus tenderness. Oropharynx: Narrowed, elevated base of tongue and dependent soft palate. Posterior pharynx is crowded. There is no micrognathia or retrognathia. Neck: Without adenopathy. Trachea is midline. Lungs are clear. No wheezing, rhonchi or crackles. Heart: S1, S2, regular. Extremities: No edema, clubbing or calf tenderness. Neurologic: Grossly nonfocal.
PHYSICAL EXAMINATION: The examination reveals a gentleman who appears in no distress. He is afebrile. Pulse is regular. Respiratory rate is normal. No external scars, lesions or masses in the head and neck area. No palpable sinus tenderness. No salivary gland masses. Facial strength is symmetric. Extraocular muscles are full. External auditory canals and TMs are normal. No clinical hearing problems. Anterior rhinoscopy is normal. No dental problems. The oropharynx shows symmetric tonsillar fossa. No masses or lesions. Posterior pharyngeal wall is normal. Mirror examination of the larynx and nasopharynx shows no masses or lesions. No neck masses. No palpable lymph nodes or thyroid masses. Cranial nerves are intact.
PHYSICAL EXAMINATION: A pleasant female in no distress. Vital Signs: Blood pressure 148/68, pulse 72, weight 144 pounds, oxygen saturation 88%, pain score 0. HEENT: Pupils are equal and reactive. Nasal mucosa is noncongested. Oropharynx is clear. JVP is mildly elevated. Trachea is midline. Lungs: Slightly decreased breath sounds, right lung field, otherwise clear. Heart: S1, S2, regular with splitting of second heart sound. She has irregular heart sounds secondary to atrial fibrillation. Soft systolic ejection murmur noted at left lower sternal border. There is a mild right ventricular heave, mildly positive valvular reflux. Extremities: There is 1+ edema. No cyanosis, clubbing or calf tenderness. Neurologic: Alert, no apparent deficits.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 98.6 degrees, pulse 75, respirations 18, and blood pressure 122/74. Head and Neck: Sclerae are nonicteric. Oral mucosa is moist. Cranial nerves are intact. Lungs: Clear bilaterally. No wheezes or rales. Heart: Regular rate and rhythm. No murmurs. Abdomen: Protuberant but soft throughout. Mild four-quadrant discomfort without peritoneal irritation. Mild rebound tenderness but no guarding. No flank tenderness. Extremities: Normal. Skin: Warm and dry. Motor strength is intact.
PHYSICAL EXAMINATION: General: The patient is slightly lethargic but easily arousable. She appears her stated age. Body habitus is endomorphic and she is morbidly obese. Her vital signs are currently stable. The patient is afebrile. Skin/Extremities: No skin rashes or lesions are noted. No cyanosis, clubbing or edema of the extremities. Head and Neck: The head is normocephalic and atraumatic. Head and neck are nontender without thyromegaly or adenopathy, carotid upstrokes 1+/4. No cranial or cervical bruits. The neck is supple with full range of motion. Heart: Regular rate and rhythm. Lungs: Clear to auscultation. Abdomen: Soft and nontender. Back: Straight without midline defect. Neurologic: Higher cortical function/mental status: The patient is alert, orientation cannot be tested except she knows she is in the hospital and she is able to recognize her relatives. She has some amount of expressive aphasia but can answer in short words or sentences and can answer Yes or No appropriately. No evidence of dyspraxia or agnosia. Recent and remote memory cannot be tested. Her fund of knowledge cannot be tested. The remainder of the mental status examination cannot be done at this time. Cranial Nerves: Pupils 2 mm, reacting sluggishly to 1 mm without afferent pupillary defect. Visual fields are intact to threat testing. Funduscopic examination cannot be done due to extremely small pupils. Extraocular movements are full and smooth with normal pursuits and saccades. No nystagmus is noted. There is a mild right upper motor and facial weakness present. Remainder of the cranial nerves are intact and symmetrical. Strength: Difficult to test. The patient is virtually quadriplegic. There is no movement of the upper extremities. There is a slight withdrawal response to the left lower extremity. There is also a slight withdrawal response to the right lower extremity. The patient can wiggle the toes on right foot to command. Tone is increased on the left and reduced on the right. There is mild wasting of the intrinsic muscles of the hands and feet. No involuntary movements noted. Reflexes are brisk, 1/4 in the right upper extremity, 2/4 at the right knee, absent at the right Achilles tendon. Plantar responses are upgoing bilaterally. Sensation: Appears to be intact to pinprick and light touch. There is reduction to vibratory sensation in the lower extremities, particularly on the left. Coordination: Unable to test. Gait and Station: Unable to test.
PHYSICAL EXAMINATION: General: The patient is in no acute distress. Vital Signs: The temperature is 98.8 degrees, heart rate is 106, respiratory rate is 21 and blood pressure is 122/72. HEENT: Anicteric sclerae. Pupils reactive to light. Neck: Supple without lymphadenopathy. Lungs: Clear to auscultation and percussion. Heart: Regular and rhythmic. No murmurs. Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly is present. Extremities: No edema. Distal pulses are symmetric. Neurologic: Exam is nonfocal. Skin: Examined, erythema and edema on the proximal knee and an extension of 30 cm in that area with a furuncle that is exudating old blood mixed with pus. There is also a superficial lesion on the right hand that measures 0.2 cm in diameter. It is unroofed and cultured.
PHYSICAL EXAMINATION: General: Awake, alert, but not oriented to the situation. He, however, can state and confirm the site of the tenderness in his abdominal wall. Vital Signs: His temperature is 97.7 degrees Fahrenheit, heart rate is 62 per minutes, respirations 22 per minute, blood pressure 172/75 mmHg. HEENT: Head is normocephalic. Pupils are round and reactive to light and accommodation. The patient has redness of the conjuctivae. Sclerae are anicteric. Lungs: Clear to auscultation bilaterally. Heart: Tones are distant. Heart rate is regular. No murmur heard. Abdomen: Distended. Hyperkinetic bowel sounds are present. Abdomen is distended in the right lower quadrant, but there is no rebound tenderness or muscular guarding. Liver and spleen are not palpable. The patient's abdomen is obese. Skin: Pale or dry. Extremities: He is able to move all four extremities. Strength is 5/5.
PHYSICAL EXAMINATION: General: Cachetic-appearing male who appears to be in no acute distress. Voice: Weak and breathy with good communication ability in the hospital room setting. Head and Face: Normocephalic. Nontender over the paranasal sinuses to percussion. Salivary glands are normal on palpation. Facial strength is symmetrical on inspection. Ears: Canals, TMs, and middle ear are all unremarkable otoscopically. Hearing acuity is grossly intact. Nose: The patient does have nasal prong oxygen in place. There is no sign of clot, discharge, ulceration or lesion within the right naris. The patient does have some dried, crusted blood on the left side of the septum, and the mucosa is somewhat friable anterior to this. It bleeds easily with touch. This was controlled with silver nitrate cautery. In general, the nasal mucosa is congested on the left side. Clear mucoid drainage is noted. No overtly purulent secretions are seen. Mouth and Pharynx: Edentulous. No oral or pharyngeal lesions, inflammation or exudative findings. Hypopharynx, Larynx, and Tongue Base: Without lesions on indirect inspection. Has incomplete glottic closure due to generalized weakness. He does exhibit some pooling of secretions. Neck: Without tenderness, mass, lymphadenopathy, thyromegaly or nodules.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 112/78, pulse 86 and regular, respirations 18, temperature 99.4 degrees, and oxygen saturation 98% on room air. GENERAL: This is a well-developed, well-nourished female who appears to be in no acute distress at this time with a GCS of 15. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive to light. Extraocular muscles are intact. Conjunctivae are pink. Mucous membranes are moist. Oropharynx is clear. Nasopharynx is clear. There is no hemotympanum, Battle's or raccoons. Maxilla, mandibles, zygoma, and orbits are nontender and intact. NECK: Collared. Trachea is midline. There is no JVD, stridor, subcutaneous crepitus. There is diffuse vertebral process tenderness with no bony step-off appreciated. CHEST: The patient does have tenderness to palpation in the area of the left posterolateral chest wall with no visible lesion noted. No bony step-off noted. No flail segment noted and no subcutaneous crepitus noted. There is noted to be symmetric rise and fall of the chest wall. LUNGS: Bilaterally clear to auscultation. HEART: Regular rate and rhythm with no ectopy. Heart rates in the 70s. BACK: Exam with C-spine immobilization. There is diffuse vertebral process tenderness from T1 to S1 with no bony step-off appreciated as well as some left paraspinal lumbar muscle tenderness. No spasm is appreciated. No visible lesion is noted. No CVA tenderness or scapular tenderness is noted. ABDOMEN: Soft, nontender, nondistended. PELVIS: Nontender and stable to rock. EXTREMITIES: All extremities are nontender. Neurovascularly intact with full range of motion. No visible lesions or deformities, except for the left upper extremity where the patient was noted to have diffuse tenderness to palpation involving the area of the left shoulder, the dorsal aspect of the left humerus, the left wrist including snuffbox tenderness. Of note, no visible lesions are appreciated. No soft tissue swelling is noted. There is noted to be full range of motion at all joints and extremities neurovascularly intact. NEUROLOGIC: The patient is awake and oriented x3, moving all extremities with no obvious focal or neurologic deficits. SKIN: Warm and dry.
PHYSICAL EXAMINATION: The patient appears his stated age. He had no aphasia or dysarthria. His pupils are equal, round, and reactive to light and accommodation. His visual fields are full. He had free range of motion to the extraocular muscles. Uvula, tongue, and palate move centrally and symmetrically. He had no evidence of facial weakness or sensory loss. His motor power was 5/5 in all four extremities. Deep tendon reflexes were 2+. Sensation was equal and symmetric. Stance and gait are normal.
PHYSICAL EXAMINATION: Vital Signs: Blood pressure 144/72, pulse 106, respiratory rate 18, and O2 saturation 100% on room air. Pain score is 9/10, leg pain. The patient is pleasant and cooperative. Her mood and affect are appropriate. She is alert and oriented x3. Her language is fluent. Cognitive exam is normal and she gives a good account of recent and remote events. Cranial nerves II through XII are intact with no nystagmus. Visual fields are full to confrontation. Fundi are poorly visualized. She has a strong gag reflex. Cardiac exam is normal with regular rate and rhythm. Motor Exam: She has increased tone in her left arm and leg. She has left hemiparesis with strength approximately 4/5 in her left upper extremity. She is weaker in her left leg with strength approximately 3+ to 4-/5, being weakest in hip flexion and ankle dorsiflexion. Overall, her motor exam is unchanged compared with previous. On sensory exam, she has left hemisensory loss; although, this is mild. She also has decreased pinprick sensation in a stocking distribution, which is chronic. Vibration sense is decreased in her lower extremities, left greater than right. Deep tendon reflexes are brisk throughout. Coordination is slow bilaterally, more so on the left with mild dysmetria. Gait: She has slightly delayed postural reflexes. She has a spastic quality to her gait. She has left footdrop with circumduction of her left leg. She was steady, ambulating with her quad cane. on musculoskeletal exam, she has mild tenderness in her right lumbosacral and hip region.
PHYSICAL EXAMINATION: The patient is alert and oriented x3, in no acute distress, sitting comfortably on the examining table. His pupils were equal, round and reactive to light and accommodation. Pharynx is hyperemic, but no JVD, no LAD. Thyroid was normal. Lungs: Clear on auscultation bilaterally. Heart: Regular rate and rhythm with no murmurs. There is no pain that can be provoked by pressure on the ribs or the rib spaces, and there is no provocation on any pressure from right side of the chest wall and the abdomen. While lying down, the abdomen is obese. Bowel sounds are present. There is no splenomegaly. There are some signs of left liver lobe enlargement with some pain that can be provoked on deep palpation and there is the severity of the pain that the patient already described. There is mild pain in epigastrium that can be provoked on superficial and deep palpation. The rest of the liver does not seem to be enlarged and there is some pain that can be provoked on deep inspiration during the liver palpation. There is no sign of ascites or tumor masses. There are no signs of clubbing or cyanosis in extremities.
PHYSICAL EXAMINATION: On examination, height is 5 feet 4 inches, weight is 142, blood pressure is 132/72. Pain score 0/10. Head and neck exam is benign with no adenopathy appreciated. Scar from thyroidectomy is unchanged. There is no cervical adenopathy. Breast exam was performed in both the sitting and supine position with no skin change, mass or regional lymphadenopathy. There is slight inversion in the left nipple, unchanged from prior exams. There is no regional lymphadenopathy. There is no skin change or mass within the breast tissue. Respiratory: Clear. Abdomen is soft, nontender, with no hepatosplenomegaly. There is no palpable abdominal mass. There is no inguinal adenopathy. Pelvic: Normal female external genitalia. There remains some hypopigmentation on the posterior perineum and perianal skin suggestive of lichen sclerosus. The vaginal mucosa is atrophic. The cervix is multiparous with no significant prolapse. The uterus is small and anteverted in size. The ovaries are not palpable. Rectovaginal septum is normal. Extremities show no edema. Pap smear and HPV DNA test for high-risk viral types was obtained.
PHYSICAL EXAMINATION: The pain score is 2/10 in the small joints of the hands. Gait is stable and steady. The patient is a middle-aged, thin female, in no apparent distress. HEENT: Unremarkable. The neck is supple without lymphadenopathy. Heart is regular. No extra heart sounds. Lungs are clear. Abdomen: Positive bowel sounds. Skin: No active rashes or edema at this time; although, she does have evidence of some Raynaud's in the feet at this time. There is no specific soft tissue swelling. Her lung exam does not disclose a loud P2 component. She has no elevated JVP. Neurologic exam is grossly nonfocal. Skin shows no sclerodactyly, tendon friction rubs. She has otherwise normal digital pulp. No calcinosis. Previous nailfold capillaroscopy shows a few areas of dropout with dilatation. Her musculoskeletal exam shows no active synovitis, small or large joints. She does have a positive Finkelstein maneuver on the right thumb consistent with de Quervain's tenosynovitis or bony hypertrophic changes noted over several IP joints of the toes, but no dactylitis. No tendinopathy appreciated.
PHYSICAL EXAMINATION: The patient is a well-nourished, well-developed female in no distress. Blood pressure 134/70, pulse 84, oxygen saturation 96%, weight 182 pounds. The neck circumference is 17 inches. HEENT: Pupils are equally round and reactive to light. Nasal mucosa is mildly congested. No sinus tenderness. Oropharynx: Narrowed, elevated base of tongue and dependent soft palate. Posterior pharynx is crowded. There is no micrognathia or retrognathia. Neck: Without adenopathy. Trachea is midline. Lungs are clear. No wheezing, rhonchi or crackles. Heart: S1, S2, regular. Extremities: No edema, clubbing or calf tenderness. Neurologic: Grossly nonfocal.
PHYSICAL EXAMINATION: The examination reveals a gentleman who appears in no distress. He is afebrile. Pulse is regular. Respiratory rate is normal. No external scars, lesions or masses in the head and neck area. No palpable sinus tenderness. No salivary gland masses. Facial strength is symmetric. Extraocular muscles are full. External auditory canals and TMs are normal. No clinical hearing problems. Anterior rhinoscopy is normal. No dental problems. The oropharynx shows symmetric tonsillar fossa. No masses or lesions. Posterior pharyngeal wall is normal. Mirror examination of the larynx and nasopharynx shows no masses or lesions. No neck masses. No palpable lymph nodes or thyroid masses. Cranial nerves are intact.
PHYSICAL EXAMINATION: A pleasant female in no distress. Vital Signs: Blood pressure 148/68, pulse 72, weight 144 pounds, oxygen saturation 88%, pain score 0. HEENT: Pupils are equal and reactive. Nasal mucosa is noncongested. Oropharynx is clear. JVP is mildly elevated. Trachea is midline. Lungs: Slightly decreased breath sounds, right lung field, otherwise clear. Heart: S1, S2, regular with splitting of second heart sound. She has irregular heart sounds secondary to atrial fibrillation. Soft systolic ejection murmur noted at left lower sternal border. There is a mild right ventricular heave, mildly positive valvular reflux. Extremities: There is 1+ edema. No cyanosis, clubbing or calf tenderness. Neurologic: Alert, no apparent deficits.
PHYSICAL EXAMINATION: Vital Signs: Temperature is 98.6 degrees, pulse 75, respirations 18, and blood pressure 122/74. Head and Neck: Sclerae are nonicteric. Oral mucosa is moist. Cranial nerves are intact. Lungs: Clear bilaterally. No wheezes or rales. Heart: Regular rate and rhythm. No murmurs. Abdomen: Protuberant but soft throughout. Mild four-quadrant discomfort without peritoneal irritation. Mild rebound tenderness but no guarding. No flank tenderness. Extremities: Normal. Skin: Warm and dry. Motor strength is intact.
PHYSICAL EXAMINATION: General: The patient is slightly lethargic but easily arousable. She appears her stated age. Body habitus is endomorphic and she is morbidly obese. Her vital signs are currently stable. The patient is afebrile. Skin/Extremities: No skin rashes or lesions are noted. No cyanosis, clubbing or edema of the extremities. Head and Neck: The head is normocephalic and atraumatic. Head and neck are nontender without thyromegaly or adenopathy, carotid upstrokes 1+/4. No cranial or cervical bruits. The neck is supple with full range of motion. Heart: Regular rate and rhythm. Lungs: Clear to auscultation. Abdomen: Soft and nontender. Back: Straight without midline defect. Neurologic: Higher cortical function/mental status: The patient is alert, orientation cannot be tested except she knows she is in the hospital and she is able to recognize her relatives. She has some amount of expressive aphasia but can answer in short words or sentences and can answer Yes or No appropriately. No evidence of dyspraxia or agnosia. Recent and remote memory cannot be tested. Her fund of knowledge cannot be tested. The remainder of the mental status examination cannot be done at this time. Cranial Nerves: Pupils 2 mm, reacting sluggishly to 1 mm without afferent pupillary defect. Visual fields are intact to threat testing. Funduscopic examination cannot be done due to extremely small pupils. Extraocular movements are full and smooth with normal pursuits and saccades. No nystagmus is noted. There is a mild right upper motor and facial weakness present. Remainder of the cranial nerves are intact and symmetrical. Strength: Difficult to test. The patient is virtually quadriplegic. There is no movement of the upper extremities. There is a slight withdrawal response to the left lower extremity. There is also a slight withdrawal response to the right lower extremity. The patient can wiggle the toes on right foot to command. Tone is increased on the left and reduced on the right. There is mild wasting of the intrinsic muscles of the hands and feet. No involuntary movements noted. Reflexes are brisk, 1/4 in the right upper extremity, 2/4 at the right knee, absent at the right Achilles tendon. Plantar responses are upgoing bilaterally. Sensation: Appears to be intact to pinprick and light touch. There is reduction to vibratory sensation in the lower extremities, particularly on the left. Coordination: Unable to test. Gait and Station: Unable to test.
