SkinSkin is pink, warm, dry and intact. No rashes or lesions noted.HEENTHead is normocephalic without injury. Eyes: sclera white with conjunctiva not injected. PERRLA, did not assess optic disc. Ear: hearing appropriate. Unable to visualize right TM due to cerumen in canal. Left canal patent, TM pearly grey with positive light reflex, landmark easily visualized. Nose: erythema of the nasal mucosa, erythema of the nasal turbinates. No septal deviation. No frontal or maxillary sinus tenderness. Yellow rhinorrhea. Throat: oral mucosa moist, pharynx reddened without exudates, Tonsils +1, good dentition. Neck: Trachea midline, Full ROM, no tenderness or masses, no occipital nodes, slight non tender anterior cervical lymphadenopathy.CardiovascularS1, S2 with regular rate and rhythm. No murmurs, rubs or gallops. Capillary refill 2 seconds. Radial pulses + 3.RespiratoryThorax symmetrical with good chest wall expansion. Lungs resonant. Breath sounds vesicular. No adventitious sound. Did not measure diaphragm excursion.GastrointestinalAbdomen soft, non-tender, non-distended. Bowel sounds positive in all 4 quadrants.BreastNo masses or tenderness, no discharge.
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- Fall '17
- Dry cough, nasal congestion, Sinusitis, Omnaris nasal spray, yellow nasal discharge