ALLERGIES: No history of asthma, hives, eczema or rhinitis. O. Vital signs: Temperature 99.4 F, BP 120/78 mm Hg (sitting), Pulse 98 bpm, Resp 16/min, Height 64 inches (5’4), Weight 170 lbs. Physical exam: GENERAL APPEARANCE: Well appearing, well nourished, in no acute distress. Oriented x3, normal mood and affect. Ambulates without difficulty. HEENT: Normocephalic, atraumatic, no visible or palpable masses, depressions or scaring. Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PEARRLA, normal optic discs and vessels, no exudates or hemorrhages. Hearing intact with TMs translucent and mobile. No external lesions, septum and turbinates normal. Mucous membranes moist, no mucosal lesions. No obvious caries or periodontal disease. No gingival inflammation or significant resorption. Neck is supple without lesions, bruits, or
adenopathy, thyroid is non-enlarged and non-tender. Tonsils are present at 2+ without exudate. Pharyngeal wall pink. SKIN: Good turgor, no unusual bruising or prominent lesions. Pink, warm, and dry. CARDIOVASCULAR: No cardiomegaly or thrills, regular rate and rhythm, S1 and S2 normal. No murmur or gallop. No JVD present. Precordium: no abnormal pulsations, no heaves. Apical impulse at 5 th ICS in left MCL, no thrills. S1-S2 are not diminished or accentuated, no S3-S4. Extremities are pink, warm, and dry. No edema present. All pulses 2+ and regular RESPIRATORY: Clear to auscultation and percussion. Good expansion without retractions. Non-tender. AP < transverse diameter. Chest expansion symmetric. Tactile fremitus equal bilaterally. Lung fields resonant. Diaphragmatic excursion 4cm and equal bilaterally GI: Abdomen soft, symmetrical, non-tender. Bowel sounds normal in all 4 quadrants, no tenderness, organomegaly, masses, or hernia. (Abdomen is tender in the pelvic area upon palpation). GU: Vagina and cervix without lesions or discharge. Uterus and adnexa/parametric non-tender without masses. No bladder tenderness upon palpation, no distention noted. External genitalia normal, no gross lesions or lacerations. Vagina shows healthy, pink mucosa, no gross lesions, no discharge noted. Cervix shows no lesions. Stool guaiac is negative. No CVA tenderness. (Bladder is tender upon palpation). BREASTS: The breasts are symmetrical with both nipples pointing outward. The overlying skin is normal. No dimpling is present. There are no masses or discharge. Axillary examination reveals no lymphadenopathy. NEURO: Alert and oriented x3. GCS 15. Cranial nerves II-XII intact. Sensation to pain, touch, and proprioception normal. Deep tendon reflexes normal in upper and lower extremities. No pathologic reflexes. The sensory examinations are normal, with pain, light touch, and stereognosis intact. Cerebellar function is normal. Speech is clear. Gait normal. MUSCLOSKELETAL: Normal gait and station. Full ROM. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities. Good strength bilaterally. No clubbing, cyanosis or edema. Peripheral pulses are intact, sensation intact.
- Fall '15