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Admission Physical Exam & Diagnosis Summary

The patient presented with the following vital signs: BP of 140/90 mmHg, HR of 114 bpm, and RR of 38 breaths per minute. On physical examination, the patient appeared weak and needed assistance ambulating. Lung examination revealed coarse crackles bilaterally as well as decreased tactile and vocal fremiti. Abdominal examination was unremarkable. Differential diagnoses considered were septic shock, diabetic nephropathy, and community-acquired pneumonia secondary to diabetic neuropathy.

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Lovely Reyes
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4 views9 pages

Admission Physical Exam & Diagnosis Summary

The patient presented with the following vital signs: BP of 140/90 mmHg, HR of 114 bpm, and RR of 38 breaths per minute. On physical examination, the patient appeared weak and needed assistance ambulating. Lung examination revealed coarse crackles bilaterally as well as decreased tactile and vocal fremiti. Abdominal examination was unremarkable. Differential diagnoses considered were septic shock, diabetic nephropathy, and community-acquired pneumonia secondary to diabetic neuropathy.

Uploaded by

Lovely Reyes
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd

Physical Examinations

Physical Examination upon Admission

Vital Signs

BP: 140/90 mmHg

HR: 114 bpm

RR: 38 breaths per minute


Physical Examination upon Admission

• GENERAL: weak looking, ambulatory with assistance

• HEENT: moist buccal mucosa, no oral ulcers, no palpable


cervical lymph nodes. Equally distributed black hair, no
alopecia, no active scalp lesions. Pale palpebral conjunctiva,
anicteric sclera, pupils reactive to direct and consensual light;
no periauricular pain, no discharge
Physical Examination upon Admission

• CHEST AND LUNGS: Adynamic precordium, apex beat at 5th


intercostal space midclavicular area, no adventitial sounds, no
murmurs; symmetrical chest expansion, no retractions, coarse
crackles noted on the right lung base. Crackles on the left
lower lung field from T8 down as well as on the right lower
lung field from T3 to T7. Tactile fremiti decreased on right as
well as vocal fremiti. No wheezing and ronchi noted.

• ABDOMEN: flabby abdomen, normoactive BS, soft,


nontender, no masses.

• Pulses full and equal.


Differential Diagnosis
Septic Shock secondary to Intrinsic Acute
Kidney Injury

RULE IN RULE OUT

- left plank pain - Does not meet the criteria: increase of


0.3 mg/dL (within 48 h) or 1.5–1.9
times baseline (within 7 days)
- dyspnea (KDIGO Clinical Practice Guideline
For AKI,2012)
- anemia
- no recorded history of urine sediment
- azotemia abnormalities

- Pulmonary edema and pleural


effusion

- elevated WBC
Diabetic Nephropathy
RULE IN RULE OUT

- Prior history of spot urine


- major risk factor is DM
albumin/creatinine ratio: 30 to 300 mg of
albumin per g of creatinine
- Hypertension

- anorexia - Or history of a low GFR in the absence of


microalbuminuria
- anemia

- left plank pain


- History of urine sediment abnormalities

- Pulmonary edema and pleural effusion

- elevated WBC
Main Diagnosis
CAP secondary to Diabetic Neuropathy
RULE IN RULE OUT

- anorexia
- productive cough and dyspnea
- fever, chills, headache, and cannot be completely ruled out
tachycardia
- Pulmonary edema and pleural
effusion
- lobar infiltrates
- (+) retractions
- crackles
- tactile and vocal fremiti decreased
- elevated WBC

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