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Patency of nostrilsNostrils patent bilateral. No abnormal drainage.Describe the purpose of the speculum evaluate nasal mucosa, septum, and turbinatesUsing a speculum allows for better examination of the internal nose including nasal mucosa, septum and turbinates because it widens the passages.Mouth and ThroatLips and buccal mucosaLips pink, full and intact. No dry skin. Buccal mucosa pink, moist and intact. Teeth and gumsTeeth normal, no broken or missing teeth. Gums intact,moist and pink.Tongue, hard palate, and soft palateTongue has good movement, able to protrude. Hard and soft palate intact upon visual assessment. TonsilsTonsils pink and equal. No signs of swelling or irritation.Uvula (cranial nerves IX, X)Cranial nerves IX and X intact. Able to swallow withoutdifficulty. Uvula pink, moist and intact. Moves forward when patient says “ahhhhhh”Tongue (cranial nerve XII)Tongue is pink, moist, full and intact. Cranial nerve XII intact. Able to protrude tongue and move side to side without difficulty. NeckSymmetry, lumps, and pulsationsSymmetric. No sign of lumps or pulsations.Cervical lymph nodesCervical lymph nodes present and normal; No swellingCarotid pulse (bruits if indicated)Carotid pulses present, equal and normal bilateralTracheaTrachea at midline, cartilage rings intact. Patient exhibits regular breathing. ROM (cranial nerve XI)Cranial nerve XI intact. Able to raise and drop (shrug) shoulders symmetrically and without difficultyThyroid glandPresent, moves appropriately during swallow.Chest and Lungs: Posterior and LateralThoracic cage configurationSkin characteristicsSymmetric expansionTactile fremitusSkin posterior and laterally of thoracic cage intact, color normal for ethnicity and without lesions. Patient states no tenderness. No lumps noted in area. Chest expansion symmetric. Tactile fremitus 8
Lumps or tendernesspresent. All ribs noted to be present upon visualization and palpation. Spinous processAll palpable spinous processes present, non-tender. Percussion over lung fieldsLow-pitched hollow resonance throughout lung fields when percussed. CVA tendernessNo CVA tenderness noted.Breath soundsAll lobes clear bilaterally upon auscultationAdventitious soundsNo adventitious sounds auscultated. Chest and Lungs: AnteriorRespirations and skin characteristicsEupnea. Regular depth. Skin of anterior chest/thoracic area clean, dry, intact and normal color for ethnicity. No retractions noted. Tactile fremitus, lumps, and tendernessTactile fremitus present. No lumps or tenderness noted. Percuss lung fieldsResonance present upon percussion throughout lung fields. Breath soundsAll lobes clear bilaterally upon auscultationUpper ExtremitiesROM and muscle strengthNormal active ROM. Moderate and equal strength.