CARDIOVASCULAR SAMPLE WRITE-UP



PULMONARY SAMPLE WRITE-UP

Below is a sample write-up of a patient without any significant physical exam findings. Please pretend as though you saw one of disease cases from the handout given in class & replace the physical exam findings below with those listed in the case. If no information was given in the case, assume a normal finding (i.e. such as a finding from your lab partner).(4 pts)

Date: Physical exam on Dec 5, 2009, 10:15 am

ID: Name, age, date-of-birth, profession

CC: chief complaint and duration

 

Vital signs

Temp: 98 °F Pulse:  60, regular rate and rhythm

Resp: 12 BP: 125/75 (sitting, right arm)

Pain: 0/10 2nd BP: 148/84 (seated, right arm)

Height: 5’ 3” (by pt. report) Pulse ox: (if provided)

Weight: 132# (by pt. report)

BMI: please calculate    (kg/m2)

 

Pulmonary

Inspection: Thorax is symmetric with good expansion; no kyphosis. Chest wall movements are symmetrical, with no marked use of accessory muscles.  No retractions.  Chest has no scars.

 

Palpation: No chest wall tenderness.  No costo-vertebral angle tenderness.  Chest expansion is adequate and symmetrical. Minimal (normal) tactile fremitus, equal over alll lung fields. 

 

Percussion: Lung sounds resonant over all fields.  Diaphragms descend ~4 cm bilaterally.

 

Auscultation: Vesicular breath sounds in all lung fields; no rales, wheezes, or rhonchi.  No bronchophony, egophany, or whispered pectoriloquy.

Extremities: No clubbing or cyanosis. [performed during cardiovascular exam].

Special maneuvers: Forced Expiratory Time of 3 seconds

Please include your suspected diagnosis for both cases given in the class handout, as well as a brief (1 – 3 sentences) justification for your diagnosis. What type of lung diseases are they (restrictive or obstructive)? (1 pt)

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