*************Vital Signs: BP = 126/72, Temperature = 98.2 orally, Heart rate = 86/minute, Resp Rate = 12/minute, Weight = 143 lb. (up one pound from last year), Height = 69 inches.
No fever, not hypertensive, but her heart rate is slightly elevated. No weight loss despite the diarrhea.
General: Well developed, well nourished white female, leaning against the exam table. Brow is wrinkled, arms folded tightly across her chest.
She doesn't appear chronically ill, which is reassuring. She does, however, look worried.
***************HEENT: Sclerae clear, conjunctivae not injected. Tympanic membranes clear with no fluid seen behind them. External canals without cerumen. Nose without lesions, normal turbinates. Pharynx without edema or erythema. Teeth in good repair. Neck supple, no carotid bruits. Thyroid not enlarged, no masses palpable.
Hyperthyroidism can also cause diarrhea, but it isn't usually intermittent.
Chest: Moves symmetrically. Percussion note symmetric on both sides to the bases. No wheezes, rubs or rhonchi appreciated. Air moves well. I/E ratio normal.
Breasts: No dimples or asymmetry noted. No dominant masses palpated. Axillae and supraclavicular areas without palpable adenopathy. Self exam reviewed with patient.
Normal so far....
***************Heart: Regular rate, no murmurs rubs or gallops appreciated. PMI not displaced. No jugular venous distention.
Normal exam.
Abdomen: No scars on abdominal wall. Liver percusses 10 cm in midclavicular line. Normoactive bowel sounds heard throughout. Negative Murphy's sign. Abdomen diffusely tender, but areas of tenderness not reproducible. No masses palpated.
Rectal: Normal anal tone, no external hemorrhoids seen, no palpable clotted hemorrhoids or rectal masses. Exam elicited discomfort but no cramping. No stool in vault, but wall smear is heme negative.
It is often a good idea with patients who complain of abdominal pain to palpate the abdomen several times. Ask the patient questions during the exam, to see if the patient is distractible. Pain that moves around with tenderness nearly everywhere is consistent with irritable bowel syndrome, since the entire bowel seems to be more sensitive to pressure in these patients.
GU/Gyn: External genitalia within normal limits. Vaginal vault and cervix without discharge, cervix parous and without erythema. PAP not done (last PAP 6 months ago). Bimanual: uterus retroverted, anteflexed, non-tender. Adnexa without masses or tenderness. Ovaries palpable, not enlarged.
Basically a normal exam.
Neurologic: Cranial nerves II - XII grossly intact, gait normal. Deep tendon reflexes 2+ and symmetric throughout upper and lower extremities. Muscle strength 5/5 all major muscle groups upper and lower extremities.
Normal exam.
Extremities: No clubbing, cyanosis or edema noted.
Normal as expected.
Skin: No lesions noted. Color normal.
Normal exam.