A physician is not only a scientist or a good technician. He must be more than that—he must have good human qualities. He has to have a personal understanding and sympathy for the suffering of human beings.
Albert Einstein (1879-1955)
The Techniques
The previous chapters dealt with the individual organ systems and the history and physical examinations related to each of them. The purpose of this chapter is to help the student assimilate each of the individual examinations into one complete and smoothly performed examination.
Ideally, a complete examination is performed in an orderly, thorough manner with as few movements as possible required of the patient. Most errors in performing a physical examination result from a lack of organization and thoroughness, not from a lack of knowledge. Evaluate each part of the examination carefully before moving on to the next part. The most common errors in performing the physical examination are related to the following:
• Technique
• Omission
• Detection
• Interpretation
• Recording
Errors in technique are related to lack of order and organization during the examination, faulty equipment, and poor bedside etiquette. Errors of omission are common in examinations of the eye and nose; auscultation of the neck vessels, chest, and heart; palpation of the spleen; rectal and genital examinations; and the neurologic examination. Errors of detection are those in which the examiner fails to find abnormalities that are present. The most common errors of this type involve thyroid nodules, tracheal deviation, abnormal breath sounds, diastolic murmurs, hernias, and abnormalities of the extraocular muscles. Errors in interpretation of findings occur most commonly with tracheal deviation, venous pulses, systolic murmurs, fremitus changes, abdominal tenderness, liver size, eye findings, and reflexes. The most common types of recording errors are related to descriptions of heart size and murmurs, improper terminology, and obscure abbreviations.
The following examination sequence is the one the author uses and is demonstrated in the DVD-ROM enclosed with this book. There is no right or wrong sequence. Develop your own approach. Just be sure that at the end of whichever technique you use, a complete examination has been performed.
In most situations, the patient will be lying in bed when you arrive. After introducing yourself and documenting a complete history, you should inform the patient that you are ready to begin the physical examination. Always start by washing your hands.
The reader is advised now to watch the video presentation on the DVD-ROM to review the complete physical examination of the man and the breast and pelvic examinations of the woman. The DVD-ROM will help you put the examination together.
Patient Lying Supine in Bed General Appearance
Inspect the patient's facial expression (see Chapters 13, The Chest; 14, The Heart; and 17, The Abdomen).
Vital Signs (Chapter 14, The Heart)
1. Palpate blood pressure in right arm.
2. Auscultate blood pressure in right arm.
3. Auscultate blood pressure in left arm.*
*If the blood pressure is elevated in the upper extremity, blood pressure in the lower extremity must be assessed to exclude coarctation of the aorta. The patient is asked to lie prone, and blood pressure by auscultation is determined (see Chapter 14, The Heart).
Have Patient Sit Up in Bed Vital Signs
Check for orthostatic changes in left arm (see Chapter 14, The Heart).
Have Patient Turn and Sit with Legs Dangling off Side of Bed Vital Signs
1. Palpate radial pulse for rate and regularity (see Chapter 15, The Peripheral Vascular System).
2. Determine respiratory rate and pattern (see Chapter 13, The Chest).
Head (Chapter 9, The Head and Neck)
1. Inspect cranium.
2. Inspect scalp.
3. Palpate cranium.
Face (Chapters 8, The Skin, and 9, The Head and Neck)
1. Inspect face.
2. Inspect skin on face.
Eyes (Chapter 10, The Eye)
1. Assess visual acuity, both eyes.
2. Check visual fields, both eyes.
3. Determine eye alignment, both eyes.
4. Test extraocular muscle function, both eyes.
5. Check pupillary response to light, both eyes.
6. Test for convergence.
7. Inspect external eye structures, both eyes.
8. Perform ophthalmoscopic examination, both eyes.
Nose (Chapter 11, The Ear and Nose)
1. Inspect nose.
2. Palpate nasal skeleton. *
3. Palpate sinuses (frontal, maxillary), both sides.
4. Inspect nasal septum, both sides.
5. Inspect turbinates, both sides.
Ears (Chapter 11, The Ear and Nose)
1. Inspect external ear structures, both sides.
2. Palpate external ear structures, both sides.
3. Evaluate auditory acuity, both sides.
4. Perform Rinne test, both sides.
5. Perform Weber test.
6. Perform otoscopic examination, both sides.
7. Inspect external canal, both sides.
8. Inspect tympanic membrane, both sides.
Mouth (Chapter 12, The Oral Cavity and Pharynx)
1. Inspect outer and inner surfaces of lips.
2. Inspect buccal mucosa.
3. Inspect gingivae.
4. Inspect teeth.
5. Observe Stensen's and Wharton's ducts, both sides.
6. Inspect hard palate.
7. Inspect soft palate.
8. Inspect tongue.
9. Test hypoglossal nerve function (see Chapter 21, The Nervous System).
10. Palpate tongue.
11. Inspect floor of mouth.
12. Palpate floor of mouth.
13. Inspect tonsils, both sides.
14. Inspect posterior pharyngeal wall.
15. Observe uvula as patient says ''Ah'' (see Chapter 21, The Nervous System).
16. Test gag reflex (see Chapter 21, The Nervous System).
Neck (Chapter 9, The Head and Neck)
1. Inspect neck, both sides.
2. Palpate neck, both sides.
3. Palpate lymph nodes of head and neck, both sides.
4. Palpate thyroid gland by anterior approach.
5. Evaluate position of trachea (see Chapter 13, The Chest).
Neck Vessels (Chapter 14, The Heart)
Inspect height of jugular venous pulsation, right side.
Neck* (Chapter 9, The Head and Neck)
1. Palpate thyroid gland by posterior approach.
2. Palpate for supraclavicular lymph nodes, both sides.
Posterior Chest (Chapter 13, The Chest)
1. Inspect back, both sides.
2. Palpate back for tenderness, both sides.
3. Evaluate chest excursion, both sides.
4. Palpate for tactile fremitus, both sides.
5. Percuss back, both sides.
6. Evaluate diaphragmatic excursion, right side.
7. Auscultate back, both sides.
8. Palpate for costovertebral angle tenderness, both sides (see Chapter 17, The Abdomen).
*The examiner should now go to the back of the patient while the patient remains seated with legs dangling off the side of the bed.
Sacrum (Chapter 14, The Heart)
Test for edema.
Anterior Chest* (Chapter 13, The Chest)
1. Inspect patient's posture.
2. Inspect configuration of chest.
3. Inspect chest, both sides.
4. Palpate chest for tactile fremitus, both sides.
Female Breast (Chapter 16, The Breast)
1. Inspect breast, both sides.
2. Inspect breast during maneuvers to tense pectoral muscles, both sides.
Heart (Chapter 14, The Heart)
1. Inspect for abnormal chest movements.
2. Palpate for point of maximum impulse.
3. Auscultate for heart sounds, all four positions.
Axilla (Chapter 16, The Breast)
1. Inspect axilla, both sides.
2. Palpate axilla, both sides.
3. Palpate for epitrochlear nodes, both sides (see Chapter 15, The Peripheral Vascular System).
Have Patient Lean Forward
Heart (Chapter 14, The Heart)
Auscultate with diaphragm at cardiac base.
Have Patient Lie Supine with Head of Bed Elevated About 30°
Neck Vessels (Chapter 14, The Heart)
1. Inspect jugular venous wave form, right side.
2. Auscultate carotid artery, both sides.
3. Palpate carotid artery, each side separately.
Breasts, Male and Female (Chapter 16, The Breast)
1. Inspect breast, both sides.
2. Palpate breast, both sides.
3. Palpate subareolar area, both sides.
4. Palpate nipple, both sides.
Chest (Chapter 13, The Chest)
1. Inspect chest, both sides.
2. Evaluate chest excursion, both sides.
3. Palpate for tactile fremitus, both sides.
4. Percuss chest, both sides.
5. Auscultate breath sounds, both sides.
Heart (Chapter 14, The Heart)
1. Inspect for movements.
2. Palpate for localized motion, all four positions.
3. Palpate for generalized motion, all four positions.
4. Palpate for thrills, all four positions.
5. Auscultate heart sounds, all four positions.
6. Time heart sounds to carotid pulse.
*The examiner should now go to the front of the patient while the patient remains seated with legs dangling off the side of the bed.
Have Patient Turn on Left Side
Heart (Chapter 14, The Heart)
Auscultate with bell at cardiac apex.
Have Patient Lie Supine with Bed Flat
Abdomen (Chapter 17, The Abdomen)
1. Inspect contour of abdomen.
2. Inspect skin of abdomen.
3. Inspect for hernias.
4. Auscultate abdomen for bowel sounds, one quadrant.
5. Auscultate abdomen for bruits, both sides.
6. Palpate abdomen lightly, all quadrants.
7. Palpate abdomen deeply, all quadrants.
8. Percuss abdomen, all quadrants.
9. Percuss liver.
10. Percuss spleen.
11. Test superficial abdominal reflex (see Chapter 21, The Nervous System).
12. Check for rebound tenderness.
13. Check for hepatic tenderness.
14. Evaluate hepatojugular reflux (see Chapter 14, The Heart).
15. Palpate liver.
16. Palpate spleen.
17. Palpate aorta.
18. Check for shifting dullness if ascites is suspected.
Pulses (Chapter 15, The Peripheral Vascular System)
1. Palpate radial pulse, both sides.
2. Palpate brachial pulse, both sides.
3. Palpate femoral pulse, both sides.
4. Palpate popliteal pulse, both sides.
5. Palpate dorsalis pedis pulse, both sides.
6. Palpate posterior tibial pulse, both sides.
7. Time radial and femoral pulses, right side.
8. Perform heel-to-knee test (part of neurologic examination; see Chapter 21, The Nervous System).
Male Genitalia (Chapter 18, Male Genitalia and Hernias)
1. Inspect skin and hair distribution.
2. Instruct patient to bear down, and observe inguinal area.
3. Inspect penis.
4. Inspect scrotum.
5. Palpate for inguinal nodes, both sides.
6. Elevate scrotum and inspect perineum.
Have Male Patient Stand in Front of Seated Examiner
Male Genitalia (Chapter 18, Male Genitalia and Hernias)
1. Inspect penis.
2. Inspect external urethral meatus.
3. Palpate shaft of penis.
4. Palpate urethra.
5. Inspect scrotum.
6. Palpate testicle, both sides.
7. Palpate epididymis and vas deferens, both sides.
8. Instruct patient to bear down, and observe inguinal area.
9. Test superficial cremasteric reflex (see Chapter 21, The Nervous System).
10. Transilluminate any masses.
11. Palpate for hernias, both sides.
Have Male Patient Turn Around and Bend over Bed
Rectum (Chapter 17, The Abdomen)
1. Inspect anus.
2. Inspect anus while patient strains.
3. Palpate anal sphincter.
4. Palpate rectal walls.
5. Palpate prostate gland.
6. Test stool for occult blood.
Help Female Patient to Lithotomy Position
Female Genitalia (Chapter 19, Female Genitalia)
1. Inspect skin and hair distribution.
2. Inspect labia majora.
3. Palpate labia majora.
4. Inspect labia minora, clitoris, urethral meatus, and introitus.
5. Inspect area of Bartholin's glands, both sides.
6. Inspect perineum.
7. Test for pelvic relaxation.
8. Perform speculum examination.
9. Inspect cervix.
10. Obtain Pap smear.
11. Inspect vaginal walls.
12. Perform bimanual examination.
13. Palpate cervix and uterine body.
14. Palpate adnexa, both sides.
15. Palpate rectovaginal septum.
16. Test stool for occult blood.
Have Patient Sit on Bed with Legs off Side 1
Mental Status
Ask routine questions (see Chapters 1, The Interviewer's Questions; 21, The Nervous System; and 25, The Geriatric Patient).
Face (Chapter 21, The Nervous System)
1. Test motor function of trigeminal nerve, both sides.
2. Test sensory function of trigeminal nerve, both sides.
3. Test corneal reflex, both eyes.
4. Test facial nerve, both sides.
5. Test spinal accessory nerve, both sides.
6. Test double simultaneous stimulation, both sides.
7. Perform finger-to-nose test.
Neck
Test range of motion (see Chapter 20, The Musculoskeletal System).
Hands and Wrists (Chapters 20, The Musculoskeletal System, and 21,
The Nervous System
1. Inspect hand and wrist, both sides.
2. Inspect nails, both sides (see Chapter 8, The Skin).
3. Palpate shoulder joint, both sides.
4. Palpate interphalangeal joints, both sides.
5. Palpate metacarpophalangeal joints, both sides.
6. Test light touch sensation, both sides.
7. Test vibration sense, both sides.
8. Test position sense, both sides.
9. Test object identification, both sides.
10. Test graphesthesia, both sides.
11. Test two-point discrimination, both sides.
12. Assess rapid alternating movements, both sides.
Elbows (Chapter 20, The Musculoskeletal System)
1. Inspect elbow, both sides.
2. Test range of motion, both sides.
3. Palpate elbow, both sides.
4. Test upper extremity strength, both sides.
5. Test biceps tendon reflex, both sides (see Chapter 21, The Nervous System).
6. Test triceps tendon reflex, both sides (see Chapter 21, The Nervous System).
Shoulders (Chapter 20, The Musculoskeletal System)
1. Inspect shoulder, both sides.
2. Test range of motion, both sides.
3. Palpate shoulder joint, both sides.
Shins
1. Inspect skin, both sides.
2. Test for edema, both sides (see Chapter 14, The Heart).
Feet and Ankles (Chapters 20, The Musculoskeletal System, and 21, The Nervous System)
1. Inspect feet and ankles.
2. Test range of motion, both sides.
3. Palpate Achilles tendon, both sides.
4. Palpate metatarsophalangeal joints, both sides.
5. Palpate metatarsal heads, both sides.
6. Palpate ankle and foot joints, both sides.
7. Test light touch sensation, both sides.
8. Test vibration sense, both sides.
9. Test position sense, both sides.
10. Test lower extremity strength, both sides.
11. Test ankle reflex, both sides.
12. Test plantar response, both sides.
Knees (Chapters 20, The Musculoskeletal System, and 21, The Nervous System)
1. Inspect knee, both sides.
2. Test range of motion, both sides.
3. Palpate patella, both sides.
4. Perform ballottement of patella if effusion is suspected.
5. Test patellar reflex, both sides.
Have Patient Stand with Back to Examiner
Hips (Chapter 20, The Musculoskeletal System)
1. Inspect hips.
2. Test range of motion.
Spine (Chapters 20, The Musculoskeletal System, and 21, The Nervous System)
1. Inspect spine.
2. Palpate spine.
3. Test range of motion.
4. Assess gait.
5. Perform Romberg test.
The Written Physical Examination
After the examination has been completed, the examiner must be able to record objectively all the findings of inspection, palpation, percussion, and auscultation. Be precise in stating
locations of abnormalities. Small drawings may be useful to describe a shape or location better. When describing the size of a finding, state the size in millimeters or centimeters rather than comparing it with a fruit or nut, for example, because these can vary greatly in size. It is best not to use most abbreviations because they may mean different things to different readers. However, the abbreviations used in the following examples are standard and may be used. Finally, do not make diagnostic statements in the write-up; save them for the summary at the end. For example, it is better to state that ''a grade III/VI holosystolic murmur at the apex with radiation to the axilla'' is present rather than ''a murmur of mitral insufficiency.''
Patient: John Henry*
General appearance: The patient is a 65-year-old white man who is lying in bed on two pillows and is in no acute distress. He is well developed and thin and appears slightly older than his stated age. The patient is well groomed, alert, and cooperative.
Vital signs: Blood pressure (BP), 185/65/55 right arm (lying), 180/60/50 left arm (lying), 175/65/50 left arm (sitting); heart rate, 90 and regular; respirations, 16.
Skin: Pink, with small hyperkeratotic papules over the face; nail beds slightly dusky; hair thin on head; hair absent on lower portion of lower extremities; normal male escutcheon (distribution of pubic hair).
Head: Normocephalic without evidence of trauma; no tenderness present.
Eyes: Visual acuity with glasses using near card: right eye (OD), 20/60, left eye (OS) 20/40; visual fields full bilaterally; extraocular movements (EOMs) intact; PERRLA [pupils are equal, round, and reactive to light and to accommodation] xanthelasma present bilaterally, L > R; eyebrows normal; bilateral arcus senilis present; conjunctivae without injection; opacities present in both lenses, R > L; left disc sharp with normal cup-disc ratio; normal arteriovenous (AV) ratio OS; no AV nicking present OS; there is a flame-shaped hemorrhage at the 6 o'clock position OS; several cotton-wool spots are also present at the 1 and 5 o'clock positions OS; right fundus not well visualized as a result of lenticular opacity.
Ears: Pinnae in normal position; no tenderness present; small amount of cerumen in left external canal; canals without injection or discharge; Rinne test, BC > AC right ear, AC > BC left ear; Weber test, lateralization to the right ear; both tympanic membranes are gray without injection; normal landmarks seen bilaterally.
Nose: Nose straight without masses; patent bilaterally; mucosa pink with a clear discharge present; inferior turbinate on the right slightly edematous.
Sinuses: No tenderness detected over frontal and maxillary sinuses.
Throat: Lips slightly cyanotic without lesions; patient wears an upper denture; buccal mucosa pink without injection; all lower teeth are present and are in fair condition; no obvious caries; gingivae normal; tongue midline without fasciculations; no lesions seen or palpated on tongue; mild injection of posterior pharynx with yellowish-white discharge present on posterior pharynx and tonsils; tonsils minimally enlarged; uvula elevates in midline; gag reflex intact.
Neck: Supple with full range of motion; trachea midline; small (1- to 2-cm) lymph nodes are present in superficial cervical and tonsillar node chains; thyroid borders palpable; no thyroid nodules or enlargement noted; no abnormal neck vein distention present; neck veins flat while patient is sitting upright.
Chest: Anteroposterior (AP) diameter increased; symmetric excursion bilaterally; tactile fremitus normal bilaterally; chest resonant bilaterally; vesicular breath sounds bilaterally; coarse breath sounds with occasional crackles present at the bases.
Breasts: Mild gynecomastia, L > R; no masses or discharge present.
Heart: Point of maximum impulse, sixth intercostal space (PMI 6ICS) 2 cm lateral to midclavicular line (MCL); normal physiologic splitting present; no heaves or thrills are present; S1 and S2 distant; a grade II/VI high-pitched holodiastolic murmur is heard at the 2ICS at the right upper sternal border; a grade I/VI medium-pitched systolic crescendo-decrescendo murmur is heard in the aortic area; the systolic murmur is midpeaking (Fig. 22-1).
Vascular: A carotid bruit is present on the right; no bruits are heard over the left carotid, renal, femoral, or abdominal arteries; lower extremities are slightly cool in comparison with upper extremities; 1+ pretibial edema is present on the right lower extremity; 2+ pretibial edema is present on the left; mild venous varicosities are present from midthigh to calf bilaterally; no ulceration or stasis changes are present; no calf tenderness is present.
*This name is fictitious. Any similarity to any person living or dead with this name is purely coincidental.
Figure 22-1 Location of cardiac physical signs.
Abdomen: The abdomen is scaphoid; a right lower quadrant (RLQ) appendectomy scar and a left lower quadrant (LLQ) herniorrhaphy scar are present; both scars are well healed; a 3 x 3 cm mass is seen in the RLQ after coughing or straining; no guarding, rigidity, or tenderness is present; no visible pulsations are present; bowel sounds are present; percussion note is tympanitic throughout the abdomen except over the suprapubic region, where the percussion note is dull; liver span is 10 cm from top to bottom in the MCL; spleen percussed in left upper quadrant but not palpated; kidneys not felt; no costovertebral angle tenderness (CVAT) present; an easily reducible right indirect inguinal hernia is felt at the external ring.
Rectal: Anal sphincter normal; no hemorrhoids present; nontender prostate enlarged symmetrically; prostate firm without nodules felt; no luminal masses felt in rectum; stool negative for blood.
Genitalia: Circumcised man with normal genitalia; penis without induration; left hemi- scrotum 4 to 5 cm below the right; palpation of left hemiscrotum reveals dilatation of the pampiniform plexus; soft testes 2 x 3 x 1 cm bilaterally.
Lymphatic: Nodes in anterior triangle chains already noted; two firm, 1- to 2-cm, rubbery, freely mobile nodes in left femoral area; no epitrochlear, axillary, or supraclavicular nodes felt.
Musculoskeletal: Distal interphalangeal joint enlargement on both hands, causing pain on making a fist, L > R; no tenderness or erythema present; proximal joints normal; neck, arms, hips, knees, and ankles with full range of active and passive motion; muscles appear symmetric; mild kyphosis present.
Neurologic: Oriented to person, place, and time; cranial nerves I to XII intact; gross sensory and motor strength intact; cerebellar function normal; plantar reflexes down; gait normal; deep tendon reflexes as shown in Table 22-1.
Summary: Mr. Henry is a 65-year-old man in no acute distress. Physical examination reveals systolic hypertension, retinal changes suggestive of sustained hypertension, a mild cataract in his right eye, a conductive hearing loss in his right ear, tonsillopharyngitis, and gynecomastia. Cardiac examination reveals aortic insufficiency. Peripheral vascular examination reveals possible atherosclerotic disease of the right carotid artery and mild venous disease of the lower extremities. The patient has a right, easily reducible inguinal hernia. A left-sided varicocele is present. Mild osteoarthritis of the hands is also present.
Table 22-1 Deep Tendon Reflexes of Patient John Henry
|
Side |
Biceps |
Triceps |
Knee |
Achilles |
|
Right |
1 + |
0 |
2+ |
1+ |
|
Left |
2+ |
1 + |
3+ |
2+ |
Patient: Mary Jones*
General appearance: The patient is a 51-year-old African-American woman who is sitting up in bed in mild respiratory distress. She is obese and appears to be her stated age. She is well groomed and alert, but she constantly complains about her shortness of breath.
Vital signs: BP, 130/80/75 right arm (lying), 125/75/70 left arm (lying), 120/75/70 (sitting); heart rate, 100 and regular; respirations, 20.
Skin: Upper extremities slightly dusky in comparison with lower extremities; good tissue turgor; patient is wearing a wig to cover her marked total baldness; normal female escutcheon.
Head: Normocephalic without evidence of trauma; face appears edematous; no tenderness noted.
Eyes: Visual acuity using near card: OD, 20/40, OS, 20/30; visual fields full bilaterally; EOMs intact; PERRLA; eyebrows thin bilaterally; conjunctivae red bilaterally with injection present; lenses clear; both discs appear sharp with some nasal blurring; the cup-disc ratio is 1:3 bilaterally, and the cups are symmetric; the retinal veins appear dilated bilaterally.
Ears: Pinnae in normal position; no mastoid or external canal tenderness; canals without injection or discharge; Rinne test, AC > BC bilaterally; Weber test, no lateralization; both tympanic membranes clearly visualized; normal landmarks seen bilaterally.
Nose: Straight without deviation; mucosa reddish-pink; inferior turbinates within normal limits.
Sinuses: No tenderness detected.
Throat: Lips cyanotic; all teeth present except for all third molars, which have been extracted; occlusion normal; no caries seen; gingivae normal; tongue midline with markedly dilated tortuous veins on undersurface; no fasciculations of tongue noted; posterior pharynx appears within normal limits; uvula midline and elevates normally; gag reflex intact.
Neck: Full with normal range of motion; trachea midline; neck veins distended to angle of jaw while sitting upright; no adenopathy of neck noted.
Chest: AP diameter normal; symmetric excursion bilaterally; increased tactile fremitus at right base posteriorly corresponds to area of bronchial breath sounds; percussion note in this area is dull, all other chest areas are resonant; bronchophony and egophony present in area of bronchial breath sounds; crackles and wheezes present in area at right posterior base.
Breasts: Left mastectomy scar; right breast without masses, dimpling, or discharge.
Heart: PMI 5ICS MCL; normal physiologic splitting present; no heaves or thrills present; S1 and S2 within normal limits; no murmurs, gallops, or rubs present.
Vascular: There are no bruits present over the carotid, renal, femoral, or abdominal arteries; the extremities are without clubbing or edema.
Abdomen: The abdomen is obese without guarding, rigidity, or tenderness; no visible pulsations are present; bowel sounds are normal; percussion note is tympanitic throughout the abdomen; liver span is 15 cm in the MCL; spleen not percussed or palpated; kidneys not palpated; no CVAT present.
Rectal: Refused.
Pelvic: Deferred until patient more stable.
Lymphatic: No adenopathy felt in the neck chains or in the epitrochlear, axillary, supraclavicular, or femoral regions.
Musculoskeletal: Marked edema of both upper extremities, L > R; neck, arms, knees, and ankles with full range of active and passive motion; muscles appear symmetric except for upper extremities.
Neurologic: Oriented to person, place, and time; cranial nerves I to XII intact; gross sensory and motor strength intact; cerebellar function normal; plantar reflex down bilaterally; deep tendon reflexes as shown in Table 22-2.
Table 22-2 Deep Tendon Reflexes of Patient Mary Jones
|
Side |
Biceps |
Triceps |
Knee |
Achilles |
|
Right |
2+ |
2+ |
2+ |
1+ |
|
Left |
2+ |
1 + |
2+ |
2+ |
*This name is fictitious. Any similarity to any person living or dead with this name is purely coincidental.
Summary: Ms. Jones is a 51-year-old African-American woman, status post left mastectomy, in respiratory distress. She is cyanotic and has evidence of vascular engorgement of the upper half of her body. Her trachea is fixed to the mediastinum. Chest examination reveals evidence of consolidation of the right lower lobe of her lung.
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