Normal findings Flashcards
General
well-nourished, well-developed, well-groomed; no distress, appearing stated age
Vitals
Temp 98/BP 120/80/ Pulse rate 80/ Respiratory Rate 16/ O2 % SAT 100/ Weight 112/ Height 62 inches/ BMI 19.8
Eyes
Sclera anicteric, pupils equal round and reactive to light and accommodation, red reflex present, normal disc margins and fundi
Head
atraumatic, normocephalic
Ears
EAC clear contender; tympanic membrane pearly gray with visible cone of light
Nose
nares patent with no discharge, lesions, or deformities
Mouth
Mucosa dry, no lesions, good dentition no caries, oropharynx nonerythematous with no tonsillar adenopathy
Throat
neck supple with no appreciable adenopathy, thyromegaly, elevated JVP or carotid bruits.
Pulmonary
lungs clear bilaterally on auscultation; good inspiratory effort; normal diaphragmatic excursion
Cardiovascular
normal rate and rhythm, with normal S1 and S2, no gallops murmurs or rubs; no palpable heaves or thrills; PMI Left 5th ICS; no JVD or carotid bruits present.
Abdomen
soft, symmetrical, non-tender, bowel sounds active in all four quadrants, no masses, hepatosplenomegaly, or tenderness; no abdominal hernia noted. No CVA tenderness
extremities
warm, dry. no clubbing, cyanosis, or pedal edema; peripheral pulses intact and equal bilaterally.
Musculoskeletal
full active range of motion for all extremities. Neurovascularly intact with no defects. No joint deformities, swelling, erythema, or warmth.
skin
clear to palpation and inspection. no rashes, scars, or lesions noted.
neurologic
mental status: alert, awake, appropriate and completely oriented.
cranial nerves II-XII intact.
Motor strength 5/5 in all extremities
Cerebellar: finger to nose well performed. negative babinski. negative ankle clonus.
Reflexes: 2+ at the achilles, knees, triceps, and biceps.
Sensation: intact to light touch and pain bilaterally; proprioception normal; vibration normal
Ambulation: normal gait, negative romberg
