Eyes PERRLA direct and consensual pupil response EOM intact 2020 vision

Eyes perrla direct and consensual pupil response eom

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Eyes : PERRLA, +direct and consensual pupil response. EOM intact, 20/20 vision bilaterally without correction. Fundoscopic exam normal, vessels intact, optic disc with clear margins. No hemorrhage or exudate present. Ears : Bilateral external ears no lesions, masses, drainage or tenderness. Tympanic membranes intact, pearly gray, no bulging, no erythema, and landmarks appreciated bilaterally. Hearing intact bilaterally. Nose : No nasal flaring, no discharge, no obstruction, septum not deviated. Turbinates pink and moist. No polyps or lesions bilaterally. Nares patent with no edema or erythema. Throat: Oropharynx clear and mucosa moist. No erythema or exudate. Uvula midline, palate rises symmetrically. Mouth: No lesions, no thrush. Moist mucous membranes. Healthy dentition present. Tongue midline. Neck: Full range of motion with difficulty. Trachea midline. No masses. Thyroid and lymph nodes not palpable. Chest/Lungs: Thorax non-tender with symmetric expansion. Respiration regular and unlabored. No presence of a cough. Tactile fremitus equal bilaterally and greater in upper lung fields. Breath sounds clear with adventitious sounds. All lung fields with resonant percussion tones. Heart: Regular rate and rhythm; normal S1, S2; no murmurs, rubs, or gallops. Apical pulse not visible. Apical pulse palpable. JVP appears to be approximately less than 7 cm with HOB elevated to 45 degrees. No carotid bruits or JVD appreciated. Peripheral Vascular: Pulses 2+ bilateral pedal and 2+ radial bilaterally. No pedal edema. Popliteal pulses 2+ bilaterally. Abdomen: Abdomen round, soft, and non-tender without rash, palpable mass or organomegaly. Active bowel sounds. Tympany over most quadrants with scattered areas of dullness noted upon percussion. No abdominal bruits. Inguinal nodes not palpable. Genital/Rectal: Digital rectal exam demonstrates adequate tone. No nodules, masses, tenderness, or irregularities. Prostate is about 45-55 grams, rubbery, symmetrical in
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shape, slightly firmer along the right lateral border, but with no discrete nodularity. Median sulcus reduced but not obliterated. Prostate extension into rectum is 2 cm, grade II. Eternal genitalia intact. Penis circumcised. No hemorrhoids or fissures present. Musculoskeletal : Upper and lower extremities symmetrical. No focal joint inflammation or abnormalities appreciated. Full range of motion of joints. Joints without effusions or erythema. No kyphosis, lordosis, or scoliosis present. Muscle strength symmetric bilaterally with full resistance. Neurological: CN ll-Xll grossly intact. Awake, alert, and oriented to person, place and time. Patient can move all limbs on command and spontaneously. Muscle strength of upper and lower extremity groups proximally and distally at grade 5. Skin: Skin turgor within normal limits. No excessive dryness, lesions, or rashes. Tattoo present on upper right deltoid. No open areas, edema or cyanosis. ASSESSMENT: Lab Tests and Results: CBC- Normal CMP- Normal PSA- 2.4 Urine dipstick- negative for leukocyte esterase or nitrites, negative for blood.
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