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17 Cards in this Set
- Front
- Back
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General survey?
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28 year old white female, appears stated age. Walks and moves comfortably. Speech clear and coherent. Dressed appropriately for the weather.
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Head?
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skull normocephalic, atraumatic. Scalp free of masses or lesions. Hair soft texture, full distribution.
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Eyes?
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Vision: Snellen (uncorrected) both eyes 20/20, right 20/15, left 20/20. Full complement brows and lashes. Lids without edema. Sclera white, conjunctiva clear. PERRLA. Extra ocular movements intact. Full fields by confrontation. Fundoscopic exam: disk margins clear, no nicking, hemorrhages.
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Ears?
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normal position, no masses or discharge noted. No tragal or mastoid tenderness. Canals clear. TMs clear with landmarks clearly noted. Hearing intact to whisper bilaterally. AC > BC bilaterally, Weber without lateralization.
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Nose?
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midline, no masses or discharge noted. Nares patent bilaterally. Mucosa pink, no masses.
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Sinuses?
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no frontal or maxillary tenderness.
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Oropharynx?
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lips, buccal mucosa, tongue, gums pink without lesions or masses. Teeth in good repair. Uvula midline on phonation. Posterior pharynx pink without lesions, exudates, or masses. Tonsils absent.
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Neck?
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trachea midline. No JVD. No carotid bruits. No masses or adenopathy. Thyroid not palpable.
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Chest?
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AP:lateral 1:2. Thorax symmetric. Skin clear. No spinal or chest wall tenderness. Equal fremitus and respiratory expansion. Resonant to percussion. Vesicular breath sounds audible throughout lungs, no adventitious sounds.
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Breasts & axillae?
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no visible masses, discharge, or retraction signs. No palpable masses or discharge. Axillary skin clear, no adenopathy.
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Cardiac?
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No visible masses, lifts, or heaves. No thrills. Apical impulse at 5th left ICS medial to MCL. S1 > S2 at apex, S2 > S1 at base. No murmurs, gallops, or rubs.
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Peripheral vascular?
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upper and lower extremities symmetric, skin clear, warm, and dry. Pulses 2+ and equal. No peripheral edema noted.
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Abdomen?
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flat, symmetric. No scars, lesions, or masses noted. Normoactive bowel sounds noted in all quadrants. Tympanic to percussion. Liver span 6 cm in right MCL. Negative splenic percussion sign. Nontender to palpation. Liver border smooth. Kidneys and spleen not palpable. No masses detected. Negative CVA tenderness.
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Genitalia?
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normal female escutcheon. Vulva without masses. Neg. BUS. Vagina pink without dicharge, cervix smooth and pink without discharge, lesions, or masses. Os nulliparous. On bimanual exam, uterus anteverted and anteflexed. Adnexa unremarkable. No CMT. Rectovaginal confirmatory. Rectal: no hemorrhoids or masses noted. Good sphincter tone.
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Lymphatics?
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no adenopathy noted.
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Musculoskeleta?
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all joints symmetric with clear overlying skin. Joints with FROM. No crepitus.
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Neurologic?
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A & O x 3. Cranial nerves 1-12 intact. Upper and lower reflexes 2+ and symmetric, normal plantar response bilaterally. Gait smooth. Heel walk, toe walk, and tandem walk performed smoothly. Upper and lower extremity rapid alternating movements and pronator drift negative. Romberg negative. Pain, light touch, vibration, and stereognosis intact in upper and lower extremities.
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