summaries Flashcards
abdo
situation and background
on inspection they looked comfortable and they had no peripheral stigmata of disease
the pulse rate was 64 bpm and a steady rhythm
there abdomen was soft and non tender
no organomegaly and bowel sounds where present, this was a normal abdominal exam
i would reccomend a DRE and a genital exam
neuro
SB
A: on inspection there were no signs of neurolgical probelms such as scars, wasting or fasculations
tone, power, reflexes, sensation and coordination where all normal
CVS
on inspection they looked comfortable and did not demonstrate any signs of disease
the pulse rate was 64 bpm and a steady rhythm
on palpation there was no heaves and thrills and the apex beat was found in the 5th IC MCL
on auscultation first and second heart sounds were present with no added sounds
so this was a normal exam
i would reccomend an abdominal exam, blood pressure, fundoscopy, urine dipstick, ECG and to look at the obs chart
resp
the patient appeared comfortable and there were no peripheral signs of disease and no sputum
pulse rate and respiratory rate was:
chest expansion was symmetrical
on percussion the chest seemed normally resonant
on ausculation there was bilateral air entry with no added sounds
to complete this i would reccomend looking at the obs chart
if there were signs of disease a chest xray could be done and the sputum looked at