Normal Documentation Flashcards
General Appearance
the patient is a well-developed, well-nourished male resting comfortably in no acute distress
Skin
Warm and dry. good turgor. no rash, petechiae or suspicious lesions. no jaundice.
head
normocephalic, atraumatic. sclp witout lesions. hair with average texture and distribution.
eyes
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.
ears
tragus and auricle non-tender. acuity good to finger rub bilaterally. external auditory canals clear. tympanic membranes with good cone of light .
nose
mucosa pink. septum midline.
lymph nodes
occipital, post-auricular, pre-auricular, submandibular, submental, cervical or supraclavicular adenopathy.
thorax and lungs
chest wall expansion symmetrical. resonant to percussion. breath sounds vesicular with no added sounds.
breasts
symmetric and without erythema, tenderness, skin changes or masses. nipples without discharge.
cardiovascular
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.
abdomen
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.
extremities
no clubbing, cyanosis or edema. radial, femoral, popliteal, posterior tibial and dorsalis pedis pulses 2+ bilaterally
genital female
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)
genital male
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
rectal (male and female)
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.
MSK
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.
Neuro: Mental Status
Alert and oriented
Cranial Nerves
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
Reflexes
biceps, triceps, brachioradialis, patellar, ankle reflexes 2+ bilaterally, toes down going on babinsky
sensory
light touch, pinprick, vibration and proprioception intact
motor
good bulk and tone. strength 5/5 throughout
coordination
rapid alternating movements, finger tapping, finger to nose and heel to shin intact.
gait
steady and without ataxia. able to tandem walk. walk on heels and walk on toes.
romberg
romberg negative
