Normal Documentation Flashcards
General appearance
The patient is a well-developed, well nourished individual resting comfortably in no acute distress.
Skin and Nails
Skin is warm and dry, good turgor. No rash, petechiae, or suspicious lesions. No jaundice. Nails without clubbing or cyanosis.
Head
Normocephalic, atraumatic. Scalp without lesion. Hair with average texture and normal distribution.
Eyes
Visual acuity 20/20 bilaterally. Conjunctiva pink; sclera white, pupils are equal, round, reactive to light and accommodation. Extraocular movements intact. Visual fields full by confrontation. Optic disc has sharp margins 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 membrane translucent with good cone of light.
Nose
Mucosa is pink without lesions or polyps. Septum midline.
Mouth/ Throat
Moist mucous membranes without lesions. Good dentition. Oropharanx without erythema, tonsillar enlargement, of exudates. Soft palate rises symmetrically. Tongue midline.
Neck
Supple with full range of motion. Trachea midline. Thyroid without enlargement, nodule, or tenderness.
Lymph Nodes
No occipital, posterior auricular, preauricular, tonsillar, submandibilar, submental, cervical, supraclavicular, or axillary adenopathy.
Thorax/Lungs
Chest wall expansion symmetrical. Resonant to percussion. Breath sounds vesicular with no added sounds. Lungs clear to auscultation without crackles, wheezes, or rhonchi.
Heart
PMI in the fifth intercostal space, midclavicular line. Regular rhythm, normal S1 and S2 with physiologic splitting of S2. No murmurs, gallops, or rubs. Carotid upstrokes brisk and without bruits bilaterally. JVP 3 cm above the sternal angle.
Extremities
No clubbing, cyanosis, or edema. Posterior tibial and dorsalis pedis pulses 2+ bilaterally.
Musculoskeletal
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: Cranial Nerves
Cranial Nerves:
II: Visual acuity 20/20 bilaterally. Visual fields full by confrontation. Pupils equal, round, and reactive to light and accommodation. Disc margins sharp.
III, IV, VI: Extraocular movements intact.
V: Temporal and masseter 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.
Neuro: Reflexes
Biceps, triceps, brachioradialis, patellar, ankles reflexes 2+ bilaterally, toes down going on Babinski.
Neuro: Sensory
Light touch, pinprick, vibration, and proprioception intact.
Neuro: Motor
Motor: Good bulk and tone. Strength 5/5 throughout.
Neuro: Coordination
Rapid alternating movements, finger tapping, finger to nose and heel to shin intact.
Neuro: Gait
Steady and without ataxia. Able to tandem walk, walk on heels, and walk on toes.
Neuro: Romberg
Romberg: Maintains balance with eyes closed.
Abdomen
Flat, soft, normoactive bowel sounds, nontender. No scars or striae. No aortic or renal bruits. No masses. Live spam 7cm in midclavicular line; edge smooth and palpable 1 cm below the right costal margin. No splenomegaly. Aorta within 2 cm.
