Pupils react equally to light and accommodation

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Pupils react equally to light and accommodation, assessing CN III. Eyes smoothly transition to the six cardinal fields of gaze without deviation , assessing CN II, IV, and VI. No nystagmus. No abnormalities in red reflex. Peripheral vision presents bilaterally. C entral visual acuity; 20/20 bilaterally, and capable of reading small print, assessing CN II. Auricles in proper alignment, no lesions, or masses. No cerumen bilaterally. Tympanic membranes gray. No exudates or redness noted. Positive Whisper test bilaterally; assessing CN VIII. Nares patent bilaterally. Mucosa is pink and moist. No polyps, drainage, or septal deviation. No sinus tenderness noted. Red glow present upon trans- illumination of sinuses. Accurately identify the smell of coffee, assessing CN I. Oral cavity is pink, moist, and has no lesions. No dental appliances to remove; good dental health with strong bite; assessing CN V. Tongue in midline without lesions. Uvula is midline. Uvulas rises and is without deviation when saying “ah”; assessing CN X. Gag
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Page 5 of 6 reflex intact. No redness, swelling, or lesions in pharynx. Can identify the taste of sugar; assessing CN IX. Chest and Lungs: No distress or labored breathing. No chest pain. No tenderness upon palpation. No CVA tenderness. Resonant percussion throughout. Tactile fremitus symmetrically. Auscultated clear lung sounds bilaterally. No adventitious sounds noted. Cardiovascular: S1 and S2 heard, no S3 or S4. No gallops, rubs, or murmurs. Pulses present radial 3+ and pedal 3+. Capillary refill < 3 sec bilaterally on upper and lower extremities. No palpitations or syncope noted. Allen’s test < 3 seconds. No edema. Breast: Full exam deferred. No complaints of pain or swelling. Educated on self-breast examination Gastrointestinal : Abdomen is round, soft, and symmetrical. Umbilicus is midline. No rashes, masses, or lesions. No pulsations visible. Bowel sounds present x 4 but hypoactive. Abdomen is hyperresonance to percussion. Abdomen is hard with tenderness upon palpation. Pain 6/10 at left lower quadrant upon palpation. Liver not palpable. Spleen not palpable. Negative McBurney’s sign. Negative Murphy’s sign. No ascites noted. Report occasional nausea without vomiting. Musculoskeletal : No weakness, pain, or crepitus noted. Full ROM present in all joints. No pain noted upon ROM of joints. No decreased muscle strength when opposing force applied to ROM. Normal spinal curvature. Deep tendon reflex of +2 obtained and symmetrical to patella and biceps bilaterally. Babinski reflex negative. Flexion and extension maintained against resistance and without tenderness. Lymphatic: No palpable lymph nodes. Genitalia : Deferred. Neurologic: Awake, alert, and oriented x3. No slurred speech, vertigo. Patient provides appropriate responses and can follow simple command and instructions. Cranial nerves I-XII intact. Good coordination and smooth rapid alternating movement. Negative Romberg. Positively differentiates dull and sharp sensations.
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  • Fall '19
  •  Essential, Date of patient encounter

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