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Head is normocephalic, atraumatic. Bilateral eyes with equal hair distribution on lashes and eyebrows, lids without lesions, no ptosis or edema. Conjunctiva pink, no lesions, white sclera. PERRLA bilaterally. EOMs intact bilaterally, no nystagmus. Mild retinopathic changes on right. Left fundus with sharp disc margins, no hemorrhages. Snellen: 20/20 right eye, 20/20 left eye with corrective lenses. TMs intact and pearly gray bilaterally, positive light reflex. Whispered words heard bilaterally. Frontal and maxillary sinuses nontender to palpation. Nasal mucosa moist and pink, septum midline. Oral mucosa moist without ulcerations or lesions, uvula rises midline on phonation. Gag reflex intact. Dentition without evidence of caries or infection. Tonsils 2+ bilaterally. Thyroid smooth without nodules, no goiter. No lymphadenopathy.
RespiratoryStudent DocumentationModel DocumentationSubjectivePt denies shortness of breath, difficult breathing, wheezing or cough. Pt has history of asthma. Denies sinus pressure or rhinnorhea.Reports no shortness of breath, wheezing, chest pain, dyspnea, or cough.ObjectivePeak flow x3: FVC 3.91, FEV 3.15= FEV1/FVC ratio of 80.5% Pt in no obvious distress, breathing unlabored, chest symmetrical, riseand fall of chest even. Breath sounds clear and equal bilaterally in all fields. Tympanic resonance to percussion anterior and posterior chest with no dullness. Fremitus normal.Chest is symmetric with respiration, clear to auscultation bilaterallywithout cough or wheeze. Resonant to percussion throughout. In office spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%.CardiovascularStudent DocumentationModel DocumentationSubjectivePt denies chest pain, palpitaitons, or edema. No history of anemia Reports no palpitations, tachycardia, easy bruising, or edema.
Student DocumentationModel Documentationor easy bruising.ObjectiveS1, S2 heard with normal rate and rythm, no murmurs or gallops noted on auscultation. Pulses present in all extremeties 2+, no thrills. No edema in extremities, PMI MCL 5th intercostal space. Carotid pulsespresent with no bruit. Capillary refill <3 sec in all extremities. No abdominal, iliac, renal or femoral bruits. No JVD.Heart rate is regular, S1, S2, without murmurs, gallops, or rubs. Bilateral carotids equal bilaterally without bruit. PMI at the midclavicular line, 5th intercostal space, no heaves, lifts, or thrills. Bilateral peripheral pulses equal bilaterally, capillary refill less than3 seconds. No peripheral edema.AbdominalStudent DocumentationModel DocumentationSubjectivePt denies any nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort. Reports eating healthier but no change in appetite. No difficulty urinating or excessive urinating. Denies bowel or bladder dysfunction.Gastrointestinal: Reports no nausea, vomiting, pain, constipation, diarrhea, or excessive flatulence. No food intolerances. Genitourinary: Reports no dysuria, nocturia, polyuria, hematuria, flank pain, vaginal discharge or itching.
Student DocumentationModel DocumentationObjectiveAbdomen no visible brusing or lesions, protuberant, and excessive hair around umbilicus. Bowels sounds normoactive in all quadrants. No tenderness, guarding, no masses on deep and light palpation. Tympanic on percussion and no CVA tenderness. Organs