SOLVED140

PE and Lab Tests Gen• WDWN muscular, white male in NAD • Wears glasses • Patient is friendly, soft-spoken, and cooperative and appears to be his stated age • He appears to be of ideal body weight Vital Signs BP​138/80RR​16 and unlaboredHT​6 ft-1 inP​69 and regularT​98.3°FWT​174 lbs HEENT• NC/AT • Pupils equal at 3 mm with normal response to light • EOMI • Clear sclera • (-) nystagmus and conjunctivitis • Funduscopic exam normal • TMs WNL bilaterally • Good dentition • Oral mucosa pink and moist with no lesions Skin• Warm and dry with normal color and turgor • (-) obvious icterus, spider angiomata, palmar erythema, and other types of rash or skinlesions • (+) large tattoos on both forearms, lower legs, and lower back Neck• Neck supple • (-) cervical, supraclavicular, and axillary lymphadenopathy • (-) thyromegaly, carotid bruits, masses, and JVD Heart• RRR • S1 and S2 normal • (-) S3, S4, rubs, murmurs, and gallops Lungs/Chest/Back• CTA & P bilaterally • Mild scoliosis noted Abd• Soft and non-distended • Moderate hepatomegaly and tenderness in RUQ with light palpation • (-) splenomegaly, ascites, masses, and bruits • (+) BS Ext• (-) CCE • Peripheral pulses 2+ throughout and without bruits • Normal ROM Genito/Rect• (-) masses, prostate enlargement, hemorrhoids, melena, and testicular atrophy • Normal anal sphincter tone Neuro• A&Ox3 • CNs II-XII intact • DTRs 2+ throughout • (-) focal deficits • Toes downgoing • Sensation, coordination, and gait normal • Muscle strength 5/5 in all four extremities • Capillary refill normal at < 2 secs Part 2: Review the following sections: Gen, Vital Signs, HEENT, Skin, Neck, Heart, Lungs, Abd, Ext, Rect, Neuro, What assessment data are RELEVANT and have clinical significance to the nurse? Relevant Data from Gen and vital signs Clinical Significance Relevant Data from HEENT, Skin, Neck, Heart, Lungs, Abd, Ext, Rect, and Neuro Clinical Significance SCIENCE HEALTH SCIENCE NURSING NURS MISC

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