Normocephalic, atraumatic. No deformities. Facial feature symmetry. Temporal arteries non- tender to palpation. Frontal and maxillary sinuses non-tender. Eyelids: no ptosis erythema or swelling. Conjunctivae: pink, no discharge. Sclerae: anicteric. Orbital area: no edema, redness, tenderness, or lesions noted. Visual acuity with Snellen pocket card: right eye (OD) 20/20, left eye (OS) 20/20 Eyes H-test: normal Pupils equal and normal reactive. Bilateral arteriovenous (AV) nicking and cotton-wood spots Normal appearing external structures. No deformities or edema. No discharge noted. Canals patent. Good light reflex. Normal. No hearing deficits. Normal Weber and Rinne tests. Normal. No signs of infection or obstruction. No polyps or discharge. Dentition normal. Tongue normal. Posterior pharynx without signs of infection or inflammation. No unusual odor. Neck No visible scars, deformities, or other lesions. Trachea is midline and freely mobile. No asymmetry or accessory respiratory muscle use with quiet breathing. Thyroid firm, an acceptable size for patient gender and age. No nodules palpate. Normal exam. Thyroid moves with swallowing. Full range of motion. Normal jugular venous pressure. Carotid arteries without bruits. Breast Bilaterally symmetrical, subareolar gynecomastia. Normal breast-tissue consistency; no suspicious masses. Nontender to palpation. Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary, or inguinal chains. Chest Wall and Lungs Thorax atraumatic, symmetrical, without increased A-P diameter. Normal respiratory effort and excursion. Prominent, symmetrical breasts. No tenderness, lumps, or masses. Normal tactile fremitus. All superficial thoracic lymph nodes (axillary, infraclavicular, supraclavicular) are non-palpable or of normal size and consistency. Dullness to percussion over lower lung fields bilaterally. Fine crackles lower lobes bilaterally. Heart PMI nondisplaced Normal jugular venous pressure
Normal heart sounds S1/S2 No significant change while standing, squatting, during Valsalva maneuver or with sustained handgrip. Abdomen Abdomen atraumatic; mildly obese, nondistended Normal bowel sounds in all quadrants Abdominal/femoral arteries sounds normal Abdomen mildly obese, nondistended. No HSM, mass, or herniation. No abdominal abdominal- aortic pulsation. Soft, nontender to exam throughout. No tympany or shifting dullness Normal girth exam Extremities Lower legs look swollen bilaterally. 4+ pitting edema lower extremities bilaterally Musculoskeletal No bulk or tone. No rigidity.
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- Spring '16
- Shelley Ashby
- Pneumothorax, shortness of breath, pulmonary edema