CARDIOVASCULAR SAMPLE WRITE-UP



CARDIOVASCULAR 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 pt)

Date: Physical exam on 2 January 2007, 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)

Weight: 132# (by pt. report)

BMI: please calculate    (kg/m2)

 

Cardiac

Inspection: Chest is symmetric, no scars.  No cardiac heaves or lifts.  Symmetrical expansion with respiration, no other wall motions.

Palpation: No thrills appreciated.  Point of maximal impulse (PMI) (apical impulse) noted at midclavicular line, in fifth intercostal space.

Auscultation: Normal S1 and S2, with regular rate and rhythm.  S2 > S1 at the base, S1 > S2 at apex.  No splitting of the heart sounds heard.  No murmur.  No S3 or S4, no friction rub.

Maneuvers: No murmur is heard while squatting or upon release of valsalva, standing or during valsalva strain.

 

Draw timing diagram:

S1 S2 S1 S2

( ( ( (

Neck: 

Inspection: No jugular venous distention or pulsations. 

Auscultation: No carotid bruits, or transmitted murmur.  Carotid pulses 2/4 bilaterally.

Peripheral vascular:

Extremities

      Inspection:  No rashes, swelling, color change, or cyanosis in arms or legs.  No signs of venous stasis or arterial insufficiency in legs, with normal hair distribution, and no pigmentation around ankles.  No spider veins on legs and thighs bilaterally. No clubbing in fingernails. Capillary refill is brink ( ................
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