Appendectomy Case Study

Analysis of findings

Medical History
Examined today is a 42 years old male with a two years history of High blood pressure and a past medical history of Appendectomy secondary to a ruptured appendix approximately 10 years ago.

Assessment
Vital signs 130/90, Resp. Rate 18, Heart Rate 84, Temp 97.6. Current Weight is 190 lbs. Alert and oriented X 3, denies any pain and discomfort. Skin intact with no discoloration, bruises, rashes or any abnormities or pigmentation, skin color appropriate to race, even hair distribution, skin warm to touch and dry, no open sores was noted, skin texture smooth with even hair distribution, Nail bed pink, Cap Refill < 3 seconds; good circulation noted, no nail clubbing noted, Nails round and well groomed,…show more content…
Cranial nerves 7 intact; symmetry noted when asked to smile and Puff out cheeks, No facial drooping was noted. Temporal artery noted with no weak pulsation, TMJ shows no clicks, intact Maxillary and Frontal Sinus noted, no pain on palpation.
Pupils are equal, round, reactive to light. Visual acuity is 20/20 by snellen eye test, Sclera is white and conjunctiva is pink. External structure of the eyes shows no abnormalities, both eyes in equal alignment. Pupil size 3mm symmetrically, visual field intact by confrontation; he was able to see at equal temporal field, equal and even eye movement during test for cardinal position of gaze; no convergence insufficiency noted. Cranial nerves 111, IV and V1 intact.
Both ears are symmetrically aligned. No tenderness or pain was noted, No drainage, no perforation, no swelling or redness noted of the ear canal, Tympanic membrane is pearly gray, Shinny, translucent, non bulging or retracted. No impacted cerumen noted. Cranial Nerve 8 is intact with no auditory hearing loss. He was able to repeat words (Apple and Base ball). Good response to Rinne and Weber test, sound is symmetrical with no…show more content…
Jugular vein shows no distension. No bruits heard.
Abdomen round but not distended, left quadrant symmetrical to the right upper and lower, no visible peristalsis or aortic pulsation noted; no bruit Bowel sounds present in all four quadrant. No guarding noted, 7 cm old scar noted on right lower quadrant secondary to appendectomy. Tympanic sound noted during percussion, Liver and spleen intact, no enlargement noted, no hepatic friction rub or splenic rub heard on auscultation. Renal and iliac artery present with no bruits. Denies pain on palpation, femoral pulse present + 3 and no enlarged inguinal Lymph nodes seen.
Lower extremities noted with even hair distribution, skin warm to touch, Popliteal, posterior tibial and dorsalis pedis pulse are present bilaterally. No edema noted, toes are absent of cracks and present of hair, cap refill 3 seconds; presents good vascular circulation.
Ankle and feet shows no swelling, Negative Romberg test; no loss of balance. No pronator drift; absent of upper motor neuron disorder noted, good sensation in all upper and lower extremities including the face. Able to identify familiar objects with eyes closed, cerebellar functions are intact, present deep tendon reflexes 2 + in the biceps, Triceps, brachialradialis and patella and Achilles. Present of Babinski