3-16 AM REPORT PHYS EXAM

Physical Examination

VS:

  • Temp: 36C
  • HR 77/min
  • RR 18/min
  • 150/75 mmHg
  • 100% on RA
  • CT maxillofacial revealed Right orbital and Right maxillary sinus fracture. Ophthal/trauma/oral surgery saw patient. No need for any surgery, started on keflex prophylaxis.

 Constitutional:  Appearance: Normal appearance.

HEENT: Obvious facial injury, Right eye periorbital ecchymoses
Extraocular movements intact. Conjunctivae normal, no redness.
Pupils: Pupils are equal, round, and reactive to light.
Per optho exam: vision and visual fields normal
R cheek ecchymoses. Ears normal. Nose/mouth normal, able to speak. Mucosa dry.
Neck: Normal range of motion.

Cardio: Normal S1 S2 Reg

Pulm: Clear lungs with VBS, no crackles/wheezing

GI: Abd soft, left and right upper abdominal tenderness, lower chest tenderness. BS normal.

Mus Sk: No edema, no swollen joints, able to move all extremities. Skin is warm and dry

CNS: Seems slow, and has periods of confusion and agitation. No focal deficits. Able to speak. MOCA score was 12.

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