100%(5)5 out of 5 people found this document helpful
This preview shows page 2 - 3 out of 3 pages.
Visble acuity right 20/40, left 20/40. Injection and clear, watery discharge noted bilaterally. Conjunctiva moist and pink. Cotton wool bodiesright retina. Right disc margins blurred. Ears- External canals clear of debris. TM translucent, bony prominences visible, hearing intact. Weber,Rinne, and Whisper tests all normal. Nose- Bilateral nostrils pink, clear, thin mucous, decreased patency, moderately to severly inflamed turbinates. Throat- Red. Dry. Tonsillar hypertrophy +2 bilaterally. No exudate visble. Mouth- No lesions or sores visible. Dry, red, no broken teeth. Tongue symetrical and moves without difficulty. No signs TMJ. Neck- Supple,wihout lesions, bruits, adenopathy, thyroid non-enlarged, non-tender. Lymph nodes non-palpable. Lungs- Clear to asuculation General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented. She maintains eye contact throughout interview and examination. • Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema, conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left fundoscopic exam reveals sharp disc margins, no hemorrhages. Right fundoscopic exam reveals mild retinopathic changes. Left eye vision: 20/20. Right eye vision: 20/40. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. • Mouth/Throat: Moist buccal mucosa, no wounds visualized. Adequate dental hygiene.