Marco Mancini – Physical Assessment Transcript

Nurse: Good morning, Mr._____. My name is ____. I would be doing your physical examination today, head-to-toe. I know you have been experiencing sleeping and anxiety problems. Is it all right that I go ahead with the assessment before we start?

Client: Yes, that’s fine.

Nurse (professional demeanor): Thank you. Throughout the exam, let me know if you feel uncomfortable or need to pause. Let’s begin with checking your vital signs.

[Vital Signs – Objective]

• Temperature:6°F
• Heart Rate: 82 bpm, regular rhythm
• Respiratory Rate: 16 breaths/min, unlabored
• Blood Pressure: 148/92 mmHg
• O2 Saturation: 98% on room air
• Height: 5’10”
• Weight: 175 lbs
• BMI:1 (normal range)

Note: Elevated BP is consistent with a known hypertension diagnosis.

General Appearance

Mr. Mancini has not been given a stated age, but he seems to be of the correct age, well-dressed, and groomed. He has fair eye contact and appears to be a bit anxious. His words are clear, although at times he stops speaking about emotionally sensitive issues.

Nurse: see you are a little tense. You are good, thank you. You are open.

Neurological & Cognitive Status

• Level of Consciousness: Alert and oriented ×4 (person, place, time, situation)
• Cognition: Mild difficulty concentrating when answering emotionally triggering questions.
• Memory: Intact short- and long-term recall.
• Cranial Nerves II–XII: Grossly intact (CN VII facial symmetry observed during conversation; CN II gross visual acuity normal).

Nurse: Can you count backward from 100 by sevens?

Client: 93… 86… 79… umm… 72…

Note: Slowed processing noted, but appropriate effort and accuracy maintained.

Head, Eyes, Ears, Nose, Throat (HEENT)

• Head: Normocephalic, atraumatic
• Eyes: PERRLA, no nystagmus
• Ears: Tympanic membranes are clear bilaterally
• Nose: Mucosa pink, no congestion
• Mouth/Throat: Moist mucous membranes, no lesions, dentition intact

Skin

• Color: Normal for ethnicity
• Temperature: Warm, dry
• Turgor: Good elasticity
• Lesions: No rashes, ulcers, or abnormal findings
• Psychomotor activity: No signs of self-harm or scarring visible

Cardiovascular

• Heart sounds: S1 and S2 audible, no murmurs
• Rate & rhythm: Regular
• Peripheral pulses: 2+ bilaterally
• Capillary refill: <2 seconds

Respiratory

• Breath sounds: Clear to auscultation bilaterally
• Respiratory effort: Non-labored, even pattern
• Chest expansion: Symmetrical

Gastrointestinal

• Abdomen: Flat, soft, non-tender
• Bowel sounds: Present in all four quadrants
• No hepatosplenomegaly
• Reports no recent nausea, vomiting, or changes in appetite

Genitourinary

Subjective only as per outpatient exam protocol.

• Denies dysuria, hematuria, or frequency
• Denies sexual dysfunction
• No history of STIs reported

Musculoskeletal

• Gait: Steady
• ROM: Full range in upper/lower extremities
• Muscle strength: 5/5 bilaterally
• No joint swelling or tenderness

Psychiatric/Mental Health Observations

• Mood: “Some days I feel guilty… I get scared easily.”
• Affect: Constricted but appropriate
• Thought processes: Logical and goal-directed
• Insight/Judgment: Fair
• Suicidal ideation: Denies current or past SI/HI
• Sleep: Difficulty sleeping due to nightmares and flashbacks
• Coping mechanisms: Avoidance (e.g., violence in media), isolation

Nurse: That is some great news, _____. It is quite significant that we know how these memories can affect your ordinary life. You are not the only one, and we are here to help you with the healing process.

Plan of Care – Immediate Follow-Up

• Continue lisinopril for hypertension
• Citalopram 20 mg for depression/anxiety
• Prazosin 1 mg qHS for nightmares
• Monitor for orthostatic hypotension due to medication interaction
• Referral to individual psychotherapy (CBT)
• Psychoeducation on PTSD, medication side effects, and suicide prevention resources
• Schedule follow-up with Psychiatric NP in three weeks

Closing Statement

Nurse: You are open today, and it will make us develop a robust care plan. You are on the right track and we will proceed with our cooperation in helping you recover. Next week, we will visit you again to do therapy, and in three weeks, we will visit you to review your medications.

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