moist, no swelling, tonsils normal (2), gag reflex present. Lymph nodes not palpable in all areas, no goiter, no sinus pain. Resp: Fremitus equal bilatterally. Lung sounds and voice sounds present and normal in all areas, clear. Expansion symmetrical. Chest anterior and posterior normal upon inspection, resonant upon percussion. CV: Carotids 2+ with no thrill bilaterally, no bruits. PMI nondiscplaced, no heaves or lifts. S1 and S2 only, regular. No bruit in the AAA, arteries in abdomen and pelvis have no bruities, Pulses 2+ in all areas. Capilary refil <3 seconds in fingers and toes. No edema. GI: Bowel sounds normal in all quadrants. No masses or abnormalities upon inspection, palpation, ausculation, or percussion. Abdomen is soft with no masses. Liver is 1 cm below right costal margin, spleen not palpable, kidneys not palpable with no masses. Quadrants percussion tympanic, spleen not dull sounding. Musc: ROM in all areas normal, all muscle strengths 5/5. No CVA tenderness. DTR 2+ all over. Neuro: Finger/Nose test normal. Rapid alternating hand movements normal. Sensation normal everywhere except limited in feet, especially left foot. Able to sense position of body/fingers/toes. Graphesthesia: normal sense. Stereognosis: normal sense. Heel/sin normal. Hair, Skin, and Nails: No ridges or abnormalities in nails. Extra hair below belly button and on face. Acne present on face, acanthosis nigricans on neck. Skin normal, old scar on left shin. Hair on scalp normal. No recent or frequent illness, fatigue, fevers, chills, or night sweats. States recent 10 pound weight loss due to diet change and exercise increase. HEENT Student Documentation Model Documentation Subjective "I'm doing really well" " Reports no current headache and no history of head injury or acute visual changes. Reports no eye pain, itchy eyes, redness, or dry eyes. Wears corrective lenses. Last visit to optometrist 3 months ago. Reports no general ear problems, no change in hearing, ear pain, or discharge. Reports no change in sense of smell, sneezing, epistaxis, sinus pain or pressure, or rhinorrhea. Reports no general mouth problems, changes in taste, dry mouth, pain, sores, issues with gum, tongue, or jaw. No current dental concerns, last dental visit was 5 months ago. Reports no difficulty swallowing, sore throat, voice changes, or swollen nodes.
10/29/2017 Comprehensive Assessment | Completed | Shadow Health 5/7 Student Documentation Model Documentation Objective Scalp normal, hair normal, ears normal (bilateral pearly grey, cone of light aprox. 5 mm). Nares reddish pink with no drainage. Whisper test normal, eyelids normal, right eye 20/20 (corrective lenses) with woolen bodies and sharp disc, left eye 20/20 (corrective lenses) with sharp disc. PERRLA bilaterally. Mouth WDL, moist, tonsils 2, gag reflex present, lymph nodes not palpable, no goiter, no sinus pain. EOM normal.
- Summer '17
- Dr. Iris Malone
- Comprehensive Assessment, Diabetic neuropathy, Model Documentation, Student Documentation