74 YO Woman with an episode of confusion

Physical Examination

  • General appearance: Thin elderly female who appears her stated age and in no apparent distress.

  • Vital signs:
  • Temperature: 37° C
  • Pulse: 78/min
  • BP: 130/84 mm Hg
  • Respirations: 14/min

  • Skin: No skin rashes or bruises.

  • HEENT: Dried blood in mouth with superficial tongue laceration of left lateral aspect.

  • Pulmonary: Clear to auscultation bilaterally.

  • Cardiovascular: Regular rate and rhythm with no murmurs, rubs, or gallops.

  • Gastrointestinal: Soft, nontender and nondistended with normal bowel sounds.

  • Genitourinary: No costovertebral angle tenderness.

  • Musculoskeletal: Mild tenderness to palpation of bilateral upper extremities; no swelling, redness, or deformity. Intact range of motion.

  • Neurologic:
  • Cranial nerves: 2 to 12 intact
  • Motor exam: Muscle tone and strength in upper and lower extremities normal. No atrophy, no abnormal movements.
  • Sensory exam: Intact to light touch, pinprick, temperature, vibration, and proprioception.
  • Reflexes: Normal and symmetric throughout.
  • Coordination: Normal
  • Gait: Normal

  • Psychiatric: Alert and oriented x 3; affect: normal; mood: euthymic; memory: normal; judgment/insight: normal.