NOSE: No deformities or tenderness to palpation, mucosa pink, septum midline. THROAT: Mucosa and gingivae pink, no lesions. Tongue symmetric and midline. Tonsils present NECK: Supple with full ROM, no masses, tenderness, lymphadenopathy, no jugular veins distention or carotid bruits. RESPIRATORY: All lungs fields clear to auscultation. No wheezing. Chest expansion symmetrical. Tactile fremitus equal bilaterally. CARDIOVASCULAR: no abnormal pulsations, no heaves, Apical impulse at 5 th ICS in left MCL, S1-S2 present, no murmur auscultated PERIPHEAL: Color appropriate for racial background; No redness, cyanosis, edema, varicosities, or calf tenderness. Radial, Posterior tibial, Dorsalis pedis pulses palpable 2+ and equal bilaterally. MUSCULOSKELETAL: Temporomandibular joint-no slipping or crepitation. Neck- Full range of motion, no pain. Vertebral column- No tenderness, curvature or deformity: full extension, lateral bending and rotation. Arms and legs symmetric bilaterally with full range of motion, no pain or crepitation. Able to maintain flexion against resistance and without tenderness. Upon
inspection of muscles throughout body no atrophy noted. Homologous muscles equal bilaterally in size, strength and tone. NEUROLOGIC: Appearance behavior speech appropriate. Alert and oriented to person, place, time, with coherent thoughts. Cranial nerves I-XII intact. Reflexes intact 2+ bilaterally. GASTROINTESTINAL: Flat, symmetric, bowel sounds present in all four quadrants. No tenderness upon palpation. No masses or organomegaly noted. (Suprapubic tenderness upon palpation) GENITOURINARY: Pregnancy test negative. External Genitala skin intact, even color without inflammation, lesions or nodules. Pubic hair distribution appropriate inverted triangle without lice or nits. Labia majora midline symmetric, plump, and well formed. No nodules, rash or lesions found on clitoris. Labia minora dark pink, symmetric and moist without inflammation or lesions. Urethral opening slit like and midline. Vaginal opening patent with no foul smelling discharge. Perineum is smooth. Anus of darker pigmentation, patent, no inflammation. No tenderness, induration or discharge palpated on urethra and Skene glands. No swelling, induration, pain, erythema or discharge found upon palpation of Bartholin glands. Perineum is thick smooth and muscular. No bulging or urinary incontinence when patients bears down.
- Fall '15
- Pelvic inflammatory disease, Pelvic pain, cervical motion tenderness