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Table of Contents

Introduction
Patient Presents
Patient History
Physical Exam
Lifestyle Issues
Followup and Lifestyle Changes
Management After Lifestyle Changes
Smoking Cessation and Exercise
Followup Visits
Chest Pain
Examination
Management After Chest Pain
Blood Results
Angiogram Results
Followup
Resources

Author:

Robert L. Blake, Jr., MD

Department of Family and Community Medicine, School of Medicine, University of Missouri-Columbia
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Lifestyle Issues in Cardiac Health

Physical Exam


A physical examination is performed with the following findings.

Vital Signs: Blood pressure 152/94 mmHg in left arm, sitting; 148/92 mmHg in right arm, sitting. Pulse rate 85 per minute. Respiratory rate 16 per minute. Temperature 37.0 C. Weight 197 pounds. Height 69 inches.
 
Skin: Three seborrheic ketosis on his back. Several freckles on the dorsal surface of each hand.
 
Eyes: Pupils equal, round and reactive to light, extra ocular muscles intact, funduscopic examination shows mild arteriolar narrowing. There are no hemorrhages or exudates. The disk margins are distinct and the disks are flat.
 
Ears: Tympanic membranes appear to be normal.
 
Oral Cavity: He has good dentition. There are no oral lesions. Posterior pharynx is moderately red.
 
Neck: No lymphadenopathy or masses. Thyroid is not palpable. There are no carotid bruits. There is no neck vein distention at 30 degrees inclination.
 
Lungs: Clear to auscultation.
 
Heart: Regular rhythm. Rate 85 per minute. No murmurs or gallops.
 
Abdomen: Moderately obese, soft, no palpable organs or masses. Liver span is approximately 10 cm by percussion. No bruits auscultated.
 
Genitalia: Normal penis, bilaterally descended testicles with no scrotal masses or tenderness.
 
Rectal: Prostate is firm, non-tender with no nodules. Size is consistent with age. No rectal masses are felt. Stool is negative for occult blood.
 
Extremities: No joint abnormalities, no edema. Femoral, popliteal, dorsal pedal and posterior tibial pulses are palpable bilaterally.
 
Neurologic: Deep tendon reflexes in his lower extremities are +2 and symmetrical.

Questions

  1. What are the pertinent positive and negative findings on the physical examination?
  2. What additional information would be useful at this time? Are there any laboratory tests or x-rays that should be obtained?
  3. Is any treatment or advice appropriate at this time?
Previous: Patient History
Next: Lifestyle Issues

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Last Update: June 17 2008