Event 4: Physical Exam, Review of Systems, Labs

Physical Exam

General

• Young woman, appears healthy
• 7 months pregnant
• Alter and oriented to person, place, and time
• Affect and speech appropriate

Head, Eyes, Ears, Nose, Throat

• PERRLA
• Conjunctiva anicteric
• No lymphadenopathy

Cardiovascular/Pulmonary

• No crackles, rales, rhonchi, or wheezes
• Regular rate and rhythm with no murmurs, gallops, or rubs
• Peripheral pulses present and normal

Gastrointestinal/Genitourinary/Reproductive

• Positive bowel sounds in all four quadrants
• Non-tender to palpation of abdomen
• Tender to palpation midline anterior pelvis
• Non-tender to palpation over the flank bilaterally

Extremities/CNS/Musculoskeletal

• No cyanosis, edema, jaundice
• Normal strength and range of motion bilaterally
• Normal deep tendon reflexes bilaterally
• Gait slow and antalgic
• Patient exhibits guarding of lower abdomen

Review of Systems

General

• No weight loss
• No fatigue
• No fever

CNS/Neuro

• No visual changes
• No confusion
• No loss of consciousness
• No anxiety
• No headaches

Cardiovascular/Pulmonary

• No chest pain
• No shortness of breath
• No cough
• No palpitations

Musculoskeletal/Extremities

• Pain on ambulation
• No swelling
• No weakness

Tests and Labs

Triage Vital Signs and Lab Values

• Vital signs all within normal limits
• Afebrile
• Urinalysis negative

Previous Lab Values

The previous lab values were obtained at new patient assessment by OBGYN.

• CBC: within normal limits
• Chemistry: within normal limits
• STD Panel: all negative
• HIV: Negative
• Fetal Ultrasound: Normal

Test Your Knowledge

Which of the following aspects of the patient’s pain narrative is LEAST consistent with a diagnosis due to musculoskeletal dysfunction?