Physical exam constitutional

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Reference no: EM133924951

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Physical Exam Constitutional: Well nourished: No acute distress, Morbidly Obese Psychiatric: Alert and oriented, Recent memory intact, Remote memory intact, Mood and affect appropriate for situation. Normal attention span and concentration. HEENT: Head normocephalic and atraumatic. PERRLA Neck: Supple, No crepitus, No carotid bruits. Cardiovascular: Heart 1-rate and rhythm regular, No murmurs, rubs, or gallops. Patient is not checking home blood pressures. Reinforced importance of home monitoring. Respiratory: Respiratory rate and pattern normal, Lungs clear to auscultation bilaterally, No crackles or wheezing noted. Gastrointestinal: Abdomen soft and non-tender, No palpable masses. Genitourinary: No CVA tenderness. Lymphatic: No lymphadenopathy. Musculoskeletal additional comments: bilateral knee pain, had previous surgery on right knee and left knee tender over anterior/patello area. Integumentary: Inspection and palpation of skin and subcutaneous tissue normal, No lesions, rashes, or ulcers. No pigmentation changes, Striae, No masses/lumps in either breasts. Left breast only with pain. Suggested to decrease caffeine intake daily. If no improvement, we will consider mammography or ultrasound. Neurologic: Cranial nerves II to XII intact, Normal sensory exam.

Reference no: EM133924951

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