CPE Documentation Flashcards
General
K.K. is a pleasant, well-groomed 25 y/o caucasian female in no apparent distress.
Mental Health
Alert/oriented x4, cooperative, pleasant demeanor, affect bright, speech fluid, coherent, appropriate; intact recent and remote memory.
Skin, Hair, Nails
Skin is pale, moist, soft and without lesions. Turgor is elastic with instant recoil in all extremities. Hair is blonde, soft, and thick in a female distribution pattern. Nails are pink and symmetrical with uniform in texture and thickness.
Head
Head is erect, midline and symmetric. Scalp with smooth and without lesions or tenderness. Facial features are symmetric and well-spaced.
Eyes
Eyes, lids, and brows are in alignment bilaterally and distributed evenly. Eyelids are without weakness against resistance. No nystagmus. Conjunctiva is pink and without erythema or drainage. Sclera are clear and white. Pupils are 3mm, round, equal in size bilaterally, reactive to light, and accommodate to light. EOMs are intact in all 6 fields of gaze. Convergence occurs at 8 cm. Snellen Vision Test shows 20/20 vision without glasses or contacts.
Fundoscopic Exam
Red reflex present bilaterally. Optic disc is cream colored with crisp edges. Vessels are without nicking or hemorrhages.
Ears
Auricles are in alignment and without erythema, lesions, or tenderness. Auditory canals are clear and without lesions, masses, drainage, edema, tenderness, or erythema. Rinne test shows 2:1 air conduction to bone conduction ratio. Weber test is negative for lateralization. Whisper test is negative for hearing loss. OTOSCOPIC EXAM: TMs are pearly grey and without inflammation or deformities. Umbo, malleus, and light reflex are all present bilaterally.
Nose/Sinuses
Nares are without flaring, erythema, tenderness, or lesions. Nasal mucosa and inferior and middle turbinates are pink, moist and smooth. No drainage, polyps or septum deviation. Sinuses are non-tender and without edema during palpation and percussion.
Mouth/Throat
Lips are pink, moist, symmetric and without lesions. Buccal mucosa is pink and moist without lesions. Gums and dentition are intact without erythema, edema, or exudates. Hard and soft palates are intact without lesions. Pharynx and tonsils are 1+, pink, moist, and without exudates, erythema, or edema. Uvula is midline. Gag reflex and “ah” reflex are intact. Tongue is midline, pink, moist and without lesions, tremors, or deviation.
Neck/Lymph nodes
Neck appears supple without masses or unusual pulsations. Trachea is midline. Thyroid borders are palpable and without enlargement. Thyroid cartilages are moveable with swallowing. Full ROM in neck with flexion, extension, and lateral movements. 5/5 strength in sternocleidomastoid muscles bilaterally. No lymphadenopathy.
Pulmonary
AP diameter < lateral diameter. Lung sounds are clear upon auscultation and without adventitious breath sounds. Respirations are even and unlabored. Percussion is resonant throughout all lung fields. No tripod positioning.
Cardiac/Peripheral Vascular
S1/S2 present. Rate is regular and rhythm. No gallops, murmurs, rubs, S3, S4, clicking, or other extra sounds heard. No heaves or thrills. PMI is 5th ICS MCL. No bruits heard upon auscultation of carotid, renal, aortic, or iliac arteries. Pulses are 2+ in radial, brachial, femoral, popliteal, tibial, and pedal area. Skin is warm, pale, and moist in all extremities. Hair pattern is symmetric and even in all extremities. No cyanosis or clubbing noted in peripheral nail beds. No edema present. Capillary refill is <2 seconds in all extremities.
Breast and Lymph
Breast/Axillae/Epitrochlear nodes without lymphadenopathy. Breasts are moderate in size, conical, symmetric and without masses, lumps, dimpling rashes, color changes or tenderness. Nipples are erect symmetric and without lesions, discharge, or recent nipple inversion. Areolas are symmetric.
Abdomen
Soft, flat, non-tender and without pulsations or peristaltic movements. Bowel sounds are active in all four quadrants. Liver spans 6 cm with dull percussion. Liver border is smooth and with nodules. Spleen is unable to be percussed or palpated. Kidneys are unable to be palpated. Aorta is palpated for approx 3cm in size. No organomegaly. No masses or bulgese palpated during light or deep palpation. No CVA tenderness.
Msk
No erythema or localized edema over joint spaces. No muscle deformities. 5/5 strength in upper and lower extremities against resistance. Full ROM without cracking, popping, or pain in neck, shoulders, elbows, wrists, fingers, hips, knees, and feet. Spine and extremities in good alignment.
