Physical exam paper

Physical exam paper - N174 Suk Sojung Lab A Vital Signs...

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N174 Suk, Sojung Lab A Vital Signs T-98.1 po AP-78 reg RR-19 BP 119/73 (L) sit Ht -6’0” Wt-165 BMI -22.4 General Appearance/Mental Status Tall normal wt. well nourished, well built. Moves w/ease; clean, appropriately dressed. Alert and orientated to person, place, time, situation. Reasoning intact, judgment appropriate (answers questions appropriately and can list alternatives for a stressful situation, choose approp. action). Immediate, recent and remote memory intact. Intellect appears congruent with educational level. Relaxed and pleasant w/sense of humor appropriate to situation. Maintains eye contact. Skin/Hair/Nails Skin warm, smooth, dry, tanned (esp. on face and bilateral upper/lower extremities sun exposed area). Rapid turgor return. Few old acne and chicken pox scars on cheeks and forehead. Few dark brown nevi scattered over body. Sizes vary from 1-3 mm. One 4cmx1cm linear scars on lat ® elbow. No evidence of swelling, color changes, nails firm, well-trimmed, w/o lesions, clubbing or pitting. Multiple callous on right hand surfaces. No s/s infection.
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Head and Neck Hair-dark brown, straight, fine texture. Scant beard shaved shortly. Skull and facial features symmetric. Smiles, frowns, shows teeth, puffs cheeks, wrinkles forehead and closed eyelids tightly (CN VII intact). Facial sensation intact to (sharp superficial pain) and cotton (light touch) and clenches jaw without pain or crepitus (CN V intact). No sinus tenderness to palpation/percussion. No tonsillar, submandibular, occipital, post-or pre-auricular, submental, post. Cx or supraclavicular LNs palpable. Trachea midline without tug. Thyroid without masses, tenderness, enlargement; rises with swallowing. Full ROM of neck; equally strong to resistance (CN XI intact). Carotid pulses bilaterally strong, full; no bruits. No JVD @ 45degree. Eyes Rosenbaum handheld chart -20/20 OD, OS, OU w/o glasses (CNII intact). EOM’s intact s nystagmus (CN III, IV & VI intact), Eyes symmetric s lesions, discharge, irritation, pain, exophthalmos. Brows, lids and lashes intact. Lacrimal apparatus nontender, patent. Corneas and
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Physical exam paper - N174 Suk Sojung Lab A Vital Signs...

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