Watch here for the answers to your exam and lab choices!

 

 

 

 

 

 

 

 

 

********

Vitals: Temperature = 98.4; Respiratory Rate = 14 per minute; Heart Rate = 76 bpm (lying), 78 bpm (sitting) and 80 bpm (standing); Blood Pressure = 122/72 (lying), 118/68 (sitting) and 116/64 (standing). Weight = 120 lb. (down from usual 130 lb.)

It is important to document the orthostatic vital signs on any patient who may have or may be bleeding. This will give an idea of whether or not the patient is in trouble right now. Looks like she is ok at the moment. Confirming the claimed weight loss indicates that this has been going on for a while.

 

 

 

 

 

 

 

 

 

 

 

 

********

General: Well developed, well nourished, thin white female in no acute distress.

No problems so far.....

 

 

 

 

 

 

 

 

 

 

 

 

********

HEENT: Head without lesions, sclerae and conjunctivae normal, tympanic membranes clear with small amount of fluid bilaterally. Nose without lesions or signs of recent bleeding. Pharynx without erythema or exudates or lesions. Back teeth appear normal, breath has odor of ketones. Teeth in general appear yellowed.

The exam is notable for yellow teeth from smoking. The fluid in the middle ear is also probably from smoking, as the smoke paralyzes the cilia in the pharynx, nasopharynx, and Eustachian canal. No lesions or recent bleeding in the nose makes the UGI bleeding source less likely to be from the nose, although this should always be considered as a potential source when evaluating upper GI bleeds. It is important to check the back teeth because bulemics constantly wash acid over their teeth and wear away the enamel leading to caries. Her "bad breath" is because she hasn't eaten is a long time, not that she is in diabetic ketoacidosis.

 

 

 

 

 

 

 

 

 

 

 

 

*********

Chest (Pulmonary): Lungs auscultate and percuss clear throughout. No chest wall or CVA tenderness elicited.

Normal exam.

 

 

 

 

 

 

 

 

 

 

 

 

********

Heart: Regular rate, no murmurs, rubs or gallops noted. PMI not displaced.

I'm really reaching here - this is a normal exam, and estimation of the PMI isn't really necessary.

 

 

 

 

 

 

 

 

 

 

 

 

********

Abdomen: Liver percusses 8 cm in the mid-clavicular line, edge non-tender. Epigastric region tender to palpation, no masses appreciated. Spleen tip not palpable. Remainder of abdomen without masses or guarding or rebound. No masses appreciated throughout. Rectal exam notable for heme positive brown stool in the vault.

The exam is notable for epigastric tenderness without guarding, and heme positive stool, which taken together indicate that the most likely source of her bleeding is from her stomach.

 

 

 

 

 

 

 

 

 

 

 

********

Genitourinary: External genitalia within normal limits; Bartholin's glands and urethra also appear normal. Introitus without lesions, vault with scant clear discharge. Cervical os nulliparous, no erythema or discharge. PAP, Gonorrhea and Chlamydia cultures sent. Bimanual exam notable for "baseball-sized" nontender uterus, anteverted, retroflexed. Adnexae without masses or tenderness.

It is very important to do a pelvic exam on all women who complain of abdominal pain, even if pregnancy is not suspected. Fitz-Hugh-Curtis syndrome can lead to right upper quadrant tenderness, as previously mentioned. Since this patient gives a history of missing menses and unprotected intercourse, a pelvic exam is warranted. Besides, she needs a PAP and cultures, and this is as good a time as any!

 

 

 

 

 

 

 

 

 

 

 

 

********

Neurologic: Cranial nerves II - XII grossly intact, cerebellar grossly intact. Deep tendon reflexes not tested.

Neurologic status is not high on the list of systems to assess at this point. Cranial nerves can be assessed while doing the usual HEENT exam, except for visual fields, and by observation. Facial droops or weakness can be seen during the interview. Walking to the room and getting onto the exam table would prove difficult for a person with a cerebellar lesion. Examining the pharynx also tests for palate and tongue symmetry. So, despite not examining this system directly, most of the information can be gathered in an general way. If there is any question about this system, however, please do a complete neurologic exam.

 

 

 

 

 

 

 

 

 

 

 

 

********

Skin: Intact. Not diaphoretic.

No surprises here.

 

 

 

 

 

 

 

 

 

 

 

 

********

Extremities: Pulses 2+ throughout. Capillary refill less than 2 seconds.

Given all the above, this is not unexpected. Capillary refill might be delayed in a person with fluid loss due to dehydration or blood loss.