Preview

Proofreader #1

Powerful Essays
Open Document
Open Document
404 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Proofreader #1
Proofreader # 1

HISTORY AND PHYSICAL EXAMINATION

Patient Name: Patrick Platt

Hospital No.: 771033

Room No.: 560

Date of Admission: 08/30/2008

Admitting Physician: William Payne, MD

Admitting Diagnosis: Possible fracture of left arm.

CHIEF COMPLAINT: Pain and swelling, left upper arm.

HISTORY OF PRESENT ILLNESS: The patient is an elderly mail who fell 4 days prior to admission. He noted immediate pain and swelling in the area just below his left elbow. He was presented to the emergency room for treatment.

PAST HISTORY: Past illnesses include whooping cough as a child. Tonsillectomy in 1947. No known allergies to medication.

FAMILY HISTORY: No hereditary disorders noted. Mother and father are deceased. Two brothers are alive and well. One sister has adult set diabetes mellitus

SOCIAL HISTORY: The patient is married and has 2 children. His wife does not work outside the home.

PHYSICAL EXAMINATION: GENERAL: The patient is a well-developed, well-nourished male who appears to be in moderate distress, with pain and swelling in the upper left arm. Vital sign: Blood pressure 140/90, temperature 98.3, pulse 97, and respiration 18.

HEENT: Head normal, no lesions, Eyes, arcos senile, both eyes. Ears, impacted ceriman, left ear. Nose, clear. Mouth, dentures fit well, no lesions.

NECK: Normal range of motion in all directions.

(Continued)

HISTORY AND PHYSICAL EXAMINATION
Patient Name: Patrick Platt
Hospital No.: 771033
Date of Admission: 08/30/2008
Page 2

INTEGUMENTARY: Psoriatic lesion, right thigh, approximately 1 mL in diameter.

CHEST: Clear breathing, sounds bilateral. No riles or rhonchi noted.

HEART: Normal sinus rhythm. There is a holosystolic murmur. No friction rubs noted.

ABDOMEN: Normal bowel sounds. Liver, Kidneys, and Spleen are normal to palpitation.

GENITALIA: Testes normal descend bilaterally.

RECTAL: Prostate 2+ and benign.

EXTREMITIES: Pain and

You May Also Find These Documents Helpful

  • Satisfactory Essays

    Soap Template

    • 279 Words
    • 2 Pages

    Cardiac: Apical impulse in 5th ics at left midclavicular line, no thrill. Crisp S1 and S2, not diminished or accentuated. No extra heart sounds or murmurs.…

    • 279 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    The patient was transported from home by her daughter-n-law. According to patient daughter-n-law she has been complaining of pains in her right leg approximately one day. Family administered daily pain medications that did not help the condition of her persisting pain. After pain persisted daughter in law later brought the patient in to the emergency room for examination.…

    • 815 Words
    • 4 Pages
    Good Essays
  • Satisfactory Essays

    Resident alert, oriented and able to follow two step verbal instructions. Did not report any pain or concerns at the time of assessment. Resident's posture is moderate kyphotic with protracted shoulder blades. Mild swelling noted on her bilateral lower leg and foot, R>L. Maintained ROM and strength in the key upper and lower extremity joints and muscle groups and are within the normal limits. Her Tinetti score for gait and balance improved from 19/28 to 23/28(Moderate fall risk) during the last quarter. 3MWT 250 feet. Resident ambulates and transfers independent with supervision using 4WW.…

    • 136 Words
    • 1 Page
    Satisfactory Essays
  • Good Essays

    Esophagus Case Study

    • 732 Words
    • 3 Pages

    Do you think patient is a candidate for Esophageal cancer due to the prior damage of the esophagus?…

    • 732 Words
    • 3 Pages
    Good Essays
  • Good Essays

    Wrist Pain Case Study

    • 427 Words
    • 2 Pages

    On examination, there is edema of the hand/wrist. She maintains hands/upper extremity in guarded position. Girth measurement of the upper wrist is 16.0 cm on the right and 15.5 on the left. Upper extremity Quick DASH score is 72.73/100. Patient is…

    • 427 Words
    • 2 Pages
    Good Essays
  • Satisfactory Essays

    Tenderness Case Studies

    • 456 Words
    • 2 Pages

    On examination of the right elbow, there is tenderness to palpation over the lateral epicondyle and the extensor origin. There is pain with resisted/repetitive dorsiflexion of the wrist. Range of motion shows extension of 0 degrees, flexion of 125 degrees, pronation of 80 degrees and supination of 80…

    • 456 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Pharmacology Case Studies

    • 573 Words
    • 3 Pages

    59 year old male present to office Nasal congestion, clear rhinorrhea, and frequent sneezing that started about one week ago. Two days ago started experiencing itchy and watery eyes. Denied any fever and cough.…

    • 573 Words
    • 3 Pages
    Satisfactory Essays
  • Good Essays

    Spurling's Case Report

    • 453 Words
    • 2 Pages

    DOI: 3/3/2016. Patient is a 59-year-old male who lost his balance while unloading furniture from a truck and he fell, injuring his left hand and wrist, left shoulder, neck, back and hip. Per OMNI, he was initially diagnosed with fracture of the left hand and sprain/strain of the back and shoulder.…

    • 453 Words
    • 2 Pages
    Good Essays
  • Powerful Essays

    • Soft, filling, firm, engorged, redness, or area of tenderness or discomfort (if present, describe): Breast or filling with no tenderness present.…

    • 1114 Words
    • 5 Pages
    Powerful Essays
  • Good Essays

    Living Arrangements/Role in Family/Support Systems:The patient stated that he lives with his wife and no children. His wife will be taking care of him upon discharge. He will receive disability pay until he is able to return to work. His wife plans on taking one week off of work, but cannot financially afford to stay home any longer.…

    • 4495 Words
    • 18 Pages
    Good Essays
  • Satisfactory Essays

    This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic, atraumatic. Sclerae clear. The oropharynx is clear. The neck is supple with free range of motion and no thyromegaly. The trachea is midline and mobile. There is no crepitus noted. Lungs are clear…

    • 2062 Words
    • 9 Pages
    Satisfactory Essays
  • Powerful Essays

    Nursing Care Plan

    • 5169 Words
    • 21 Pages

    Summary of History and Physical on admission: Patient has a history of hepatitis C, alcohol abuse, cirrhosis, GI bleed, pancreatitis. Patient was lethargic, with mental status changes. Patients appearance is jaundice, stomach distended and tender to palpation.…

    • 5169 Words
    • 21 Pages
    Powerful Essays
  • Satisfactory Essays

    Chief Complaint 5

    • 502 Words
    • 3 Pages

    On exam, the little girl is awake and alert. Makes good eyes contact and is breathing regularly.…

    • 502 Words
    • 3 Pages
    Satisfactory Essays
  • Good Essays

    Capitalization Exercise

    • 383 Words
    • 2 Pages

    PAST MEDICAL HISTORY: The patient has a diagnosis of early Parkinson Disease and is treated by a neurologist for this.…

    • 383 Words
    • 2 Pages
    Good Essays
  • Good Essays

    Gastric Cancer Case Study

    • 540 Words
    • 3 Pages

    Generally, this is a thin man sitting comfortably in no acute distress. Skin is warm and dry. HEENT: Head is normocephalic, atraumatic. Pupils equal, reactive to light and accommodation. Sclerae are anicteric. Oral mucosa is moist without lesions. No JVD. No thyromegaly. Lymphatics: No cervical, supraclavicular, axillary, or inguinal adenopathy appreciated. Respiratory: Lungs are clear to auscultation bilaterally. Heart is regular rate and rhythm. Abdomen: Soft, nontender. Positive bowel sounds. Liver and spleen not palpable. Strength is 5/5 throughout. Neurological exam is…

    • 540 Words
    • 3 Pages
    Good Essays