Normal Documentation

Question 1

General Appearance

Answer 1

the patient is a well-developed, well-nourished male resting comfortably in no acute distress

Question 2

Skin

Answer 2

Warm and dry. good turgor. no rash, petechiae or suspicious lesions. no jaundice.

Question 3

head

Answer 3

normocephalic, atraumatic. sclp witout lesions. hair with average texture and distribution.

Question 4

eyes

Answer 4

visual acuity 20/20 bilaterally. conjunctiva pink, sclera white. pupils equal, round, and reactive to lightand accomodation. extraocular movements intact. visual fields full by confrontation. disc margins sharp without hemorrhages or exudates. no arteriolar narrowing or a-v nicking.

Question 5

ears

Answer 5

tragus and auricle non-tender. acuity good to finger rub bilaterally. external auditory canals clear. tympanic membranes with good cone of light .

Question 6

nose

Answer 6

mucosa pink. septum midline.

Question 7

lymph nodes

Answer 7

occipital, post-auricular, pre-auricular, submandibular, submental, cervical or supraclavicular adenopathy.

Question 8

thorax and lungs

Answer 8

chest wall expansion symmetrical. resonant to percussion. breath sounds vesicular with no added sounds.

Question 9

breasts

Answer 9

symmetric and without erythema, tenderness, skin changes or masses. nipples without discharge.

Question 10

cardiovascular

Answer 10

PMI in the 5th intercostal space, midclavicular line. regular rhythm, normal s1 and s2 with physiological splitting of s2. no murmure, gallops or rubs. carotid upstrokes brisk and without bruits bilaterally.

Question 11

abdomen

Answer 11

flat, soft, normoactive bowel sounds, nontender. no scars or striae. no aortic or renal bruits. no masses. liver span 7cm in midclavicular line; edge smooth and palpable 1 cm below the right costal margin. no splenomegaly. aorta width 2 cm.

Question 12

extremities

Answer 12

no clubbing, cyanosis or edema. radial, femoral, popliteal, posterior tibial and dorsalis pedis pulses 2+ bilaterally

Question 13

genital female

Answer 13

external genitalia without erythema or lesions. vaginal mucosa pink, well rugated and vaginal vault without discharge. parous cervix without tenderness or discharge. uterus anterior, midline and without enlargement. no adnexal tenderness or masses. (Pap smear obtained)

Question 14

genital male

Answer 14

circumcised male. no penile discharge or lesions. no scrotal swelling. testes descended bilaterally, smooth, and without masses. epididymis non-tender. no inquinal or femoral hernias

Question 15

rectal (male and female)

Answer 15

no perirectal lesions or fissures. external sphincter tone intact. rectal vault without masses.

(male) prostate smooth, non-tender and without enlargement or nodules. Median sulcus palpable. stool brown, negative for occult blood.

Chaperone: Name, Credentials.

Question 16

MSK

Answer 16

no obvious joint deformities. joints without warmth, swelling, or tenderness. good range of motion in neck, shoulders, elbows, wrists, hands, hips, knees, ankles and back.

Question 17

Neuro: Mental Status

Answer 17

Alert and oriented

Question 18

Cranial Nerves

Answer 18

II; visual acuity 20/20 bilaterally. visual fields full by confrontation. pupils equal and reactive to light and accommodation. disc margins sharp.

III, IV, and VI; extraocular movements intact.
V: temporal and massester strength intact, sensation intact to light touch.

VII: able to raise eyebrows, squeeze eyelids shut against resistance, puff out cheeks, smile, frown.

VIII: hearing intact to finger rub bilaterally

IX, X: palate rises symmetrically, uvula midline

XI: strength of sternocleidomastoid and trapezius 5/5 bilaterally

XII: tongue midline

Question 19

Reflexes

Answer 19

biceps, triceps, brachioradialis, patellar, ankle reflexes 2+ bilaterally, toes down going on babinsky

Question 20

sensory

Answer 20

light touch, pinprick, vibration and proprioception intact

Question 21

motor

Answer 21

good bulk and tone. strength 5/5 throughout

Question 22

coordination

Answer 22

rapid alternating movements, finger tapping, finger to nose and heel to shin intact.

Question 23

gait

Answer 23

steady and without ataxia. able to tandem walk. walk on heels and walk on toes.

Question 24

romberg

Answer 24

romberg negative