Presentation on theme: "PE on Admission Conscious, coherent, not in cardiorespiratory distress Vital Signs –BP: 130/80 - ok na ba to, o kailangan pang pababain –HR: 88, regular."— Presentation transcript:
PE on Admission Conscious, coherent, not in cardiorespiratory distress Vital Signs –BP: 130/80 - ok na ba to, o kailangan pang pababain –HR: 88, regular –RR: 20 –Temp: 37.7 C Warm moist skin, no active dermatoses Pink palpebral conjuctivae, icteric sclerae, no alar flaring, no epistaxis Supple neck, no palpable cervical lymph nodes, no masses, no lumps, neck veins not distended
RESPIRATORY SYSTEM –Symmetrical chest expansion, (-) retractions –Clear breath sounds, (-) crackles CARDIOVASCULAR SYSTEM –Adynamic precordium –No murmurs, heaves, thrills, lifts –Apex beat 5 th LICS MCL sinunod ko na lang yung PE ni Martin para di na tayo tanungin pa tungkol sa cardiomegaly –S2>S1 at the base with splitting; S1>S2 at the apex –Pulses full and equal –No edema, no cyanosis, no clubbing ABDOMEN –Globular abdomen, soft with no masses, lumps –No tenderness on light palpation –(-) Caput medusae and spider angiomata –Liver span 8.5 cm DRE: No skin tags, tight sphincteric tone, no pararectal tenderness, no masses, light brown stool on tactating 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 finger-to-nose test, alternate pronation and supination test –Gross motor 5/5 on all extremeties –(-) Babinski –NO nuchal rigidity
PE on Interview Vital Signs –BP: 150/90 –HR= PR: 80, normal describe contour, regularity, strength and symmetrical pulses –RR: 24, regular –Temp: 37.2 C General Survey –poorly groomed, not in pain or distress, appearance at par with age, and looks adequately nourished Level of Consciousness –conscious, coherent and oriented to time, person, place and circumstance –intact short and long term memory, calculation –mood appropriate with affect but appears restless
Skin –fair turgor –no petechiae, no ecchymosis –no edema –one verrucous lesion 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 Eyes –pale conjunctivae –partly icteric sclerae –lenses clear, smooth Nose –symmetrical nasolabial folds –midline septum –pinkish mucosa –both nares patent –(-) tenderness on sinuses, nasal discharges, alar flaring, epistaxis
Neck –midline trachea –(-) neck stiffness –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 –(-) heaves, thrills, –PMI at 5 th ICS LMCL –S1>S2 at the apex and S1
"name": "Neck –midline trachea –(-) neck stiffness –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 –(-) heaves, thrills, –PMI at 5 th ICS LMCL –S1>S2 at the apex and S1S2 at the apex and S1
ABDOMEN –flabby –tympanic –(-) fluid wave and shifting dullness –liver span at RMCL is 9 cm, smooth and sharp border –non-tender to light and deep palpation –(-) for Murphy’s sign NEUROLOGIC EXAM –ALL CRANIAL NERVES ARE INTACT able to smile, frown, puff cheek, show teeth, blow air from the mouth, raise eyebrow, squint symmetrically left eye 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 from PE, on admission icteric sclerae no epistaxis saan ito galing?
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