Physical Examination (Dr. Jefferson told not to view the patient chart)
Patient is a black, 26 year old female, in apparently good health. She wore her own gown and was sitting on the side of the left of the bed because she was instructed by the nurse. Patient was calm and was in fatigued due to the fact she had to be up right and was in slight pain at post-operative. No abnormal body, cigarette smoke, or breath odor, such as fetor hepaticus noted. Patient has good posture, gait but problems with motor activity because she needed to be assisted to move from the pain and numbness of the limb. Patient appears to be of normal height and weight for age.
No vital sign was taken or viewed from the charts. So no temperature but the patient was sweating a little while the AC was off. She show physical characteristic of fever with sweating and fatigue and cold shiver with the blanket. No pulse was taken. Blood Pressure, Weight or Height was taken or viewed from the charts. From the inspection the patient looked like she was on the overweight category of the BMI table, due to base on her waist and hip circumference. She did not have extensive amount of muscle mass to give false high BMI.
The skin inspection was done on the skin viewable which was the upper shoulder and entire arm and the legs from the lower thigh and down. The individual was black, so not a lot could be seen with discoloration on leg but on arm, just a mild discoloration of the arm at upper arm and lower arm, from the sun exposure, she mentioned. Neither the upper or lower lib showed any rash, scar or ulcers. No nicotine stain was viewed. No hand or leg examination was done or chart was viewed.
The head showed no sign of trauma or scars. The eyes were able to make contact and keep tract of the examiner. No hair loss from the eye brow (equal and symmetrical), No issue on eye lids was viewable. The pupils were brown in color and symmetrical to each other. The patient showed no viewable discoloration of sclera. No neck and throat examination were done or chart was viewed.
Lymph nodes were not inspected or examined or viewed from the charts.
Upper or Lower back was not inspected or examined or viewed from the charts.
Upper or Lower back were not inspected or examined or viewed from the charts.
Throughout the history taking process no indication of respiratory stress was displayed and she showed no sign of having trouble to catch air, tachypnea, bradypnea, or use of accessory muscle. No lung examination was done or chart was viewed.
Cardiovascular was not inspected or examined or viewed from the charts.
Abdomens was out of site and was not inspected or examined or viewed from the charts.
The hands and legs showed symmetry with one another and no swelling was viewable and tested when patient was being oriented on the bed and she needed assistant for lying down on to the bed. No venous pattern were viewable on either legs. The fingernails of her hand showed no coloration. No hand examination was done or chart was viewed.
Genital was not inspected or examined or viewed from the charts.
Rectal was not inspected or examined or viewed from the charts.
Musculoskeletal was not inspected or examined or viewed from the charts.
Neurological examination showed to be normal she had any speech, confusion or absence while having conversation with the patient. The story told by the patient flowed and no trouble when asked about person, place or time/date test. She had no trouble with the neurological examination.