Presentation on theme: "Chicco, sorry sa late ppt.. Not sure if anung ilalagay kong PE if on admission or PE ni martin. So nilagay ko na lang pareho.. Hindi ko din nilagay lahat."— Presentation transcript:
Chicco, sorry sa late ppt.. Not sure if anung ilalagay kong PE if on admission or PE ni martin. So nilagay ko na lang pareho.. Hindi ko din nilagay lahat nung PE ni martin kasi it’s TOO complete. Masyadong mahaba and baka di maniwala yung mga Doctors sa atin. Just text me if may dapat baguhin.. Tnx!
PE on Admission Conscious, coherent, not in cardiorespiratory distress VS: BP: 130/80, HR: 88bpm, regular, RR: 20cpm, Tempt: 37.7C Warm moist skin, no active dermatoses Pink palperbral conjuctiva, icteric sclerae, (-)alar flaring, no epistaxis Supple neck, no palpable cervical lymph nodes, no masses, no lumps, neck veins not distended
RESIRATORY SYSTEM –Symmetrical chest expansion, clear breath sounds, (-) retractions, (-) crackles CARDIOVASCULAR SYSTEM –Adynamic precordium –Apex beat 6 th LICS MCL –S2>S1 at the base with splitting; S1.S2 at the apex –No murmurs, heaves, thrills, lifts –Pulses full and equal, no edema, no cyanosis, no clubbing ABDOMEN –Globular abdomen, soft with no masses, lumps –No tenderness on light palpation –(-) caput medussa and spider angiomata –Liver span 8.5 cm DRE: no skin tags, tight sphincteric tone, no pararectal tenderness, no masses, light brown stool on tacting finger
Neurological Exam –Conscious, awake, oriented to person, time and place; can follow commands –CRANIAL NERVES are INTACT Papillary light refelx 2-3 mm, (+) direct and consensual light reflex, EOMs full and equal, no facial asymmetry, can clench teeth, no hearing abnormality, uvula midline, (+) gag reflex, can raise shoulders against resistance –Can do FTNT, APST (di ko alam meaning nito) –Gross motor 5/5 on all extremeties –(-) Babinski –NO nuchal rigidity
PE on Interview VS: BP: 150/90, HR= PR:80, normal and symmetrical pulses, RR:24 regular, Temp: 37.2 C, Pain= 0-1/10 General Survey – poorly groomed, not in pain or distress, looks at par with age, ectomorphic and looks adequately nourished LOC –Patient is conscious, coherent and oriented to time, person, place and circumstance. With intact short and long term memory, calculation, and mood appropriate with affect but appears restless.
Smooth, brown toned skin, with fair turgor, oily and clammy, (-) peticchiae, ecchymosis, edema or other lesions; with one verrucous and multiple papulo- follicular lesions on the anterior and posterior trunk. Hands and feet are calloused with visible healed excoriations, fissures and wounds. Latest wound on the foot has crusted already (probable entry site) pale conjunctivae with partly icteric sclerae, lens are clear, smooth symmetrical nasolabial folds, midline septum, pinkish mucosa, both nares patent, (-) tenderness on sinuses, nasal discharges, alar flaring, epistaxis
midline trachea, non- tender non rigid cervical mobility, non- tender and non- palpable lymph nodes RESPIRATORY SYSTEM –symmetrical chest expansion –Resonant to percussion in the upper, middle and lower lung fields –Symmetrical tactile fremitus; bronchial, bronchovesicular and vesicular breath sounds in appropriate representative regions CARDIOVASCULAR SYSTEM –flat and adynamic precordium –(-) lesions, tenderness, heaves, thrills, –PMI at 5 th (magkaiba sila nung PE on admission) ICS LMCL –S1>S2 at the apex and S1
–liver span at RMCL is 9 cm, smooth and sharp border –non tender to light and deep palpation –(-) for murphy’s sign NEUROLOGIC EXAM –Conscious, awake, oriented to person, time and place; can follow commands –ALL CRANIAL NERVES ARE INTACT able to smile, frown, puff cheek, show teeth, blow air from the mouth, raise eyebrow, squint symmetrically os is able to read Rosenbaum’s chart at 6 and 12 inch distance, reports peripheral vision on all fields of gaze, intact EOMs, (+) for light constriction
hears snapping fingers at 6 and 12 inches on both ears identifies area of light touch, sharp and dull sensation, vibration Tongue and uvula is midline MvtDxLv ToneEqual SizeEqual StrengthEqual S arm flexion44 S arm extension44 S arm abduction44 Elbow flexion44 Elbow extension44 Wrist abduction4- Wrist opposition4- Thumb extension4- Thumb abduction4- Finger extension44 MUSCLE TESTING Finger abduction44 Hip extension44 Hip abduction44 A foot inversion44 A foot dorsiflexion44 A foot eversion44 A plantar flexion44 Toe dorsiflexion44 Toe plantar flexion44
SALIENT FEATURES (PE) Pa-add na lang dun sa slide ni blessa Sa PE upon admission ko kinuha kasi tingin ko nandun yung salient features at wala dun sa on interview kasi magaling na siya nun e. if mali or may kulang, papalitan or padagdagan na lang.. Hehe.. Tnx!
SALIENT FEATURES (PE) icteric sclerae no epistaxis