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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