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5 Cards in this Set
- Front
- Back
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HEENT
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Head - NC/AT. Hair good texture
Eye - 20/20 visual acuity, sclera white, conjunctive pink, pupils constrict 4cm to 2cm to light, PERRLA, disc margins sharp, no hemorrhage or exudate Ears - good acuity to whispered voice, good tympanic membrane with good cone of light, AC > BC, Webber midline Nose-mucosa pink, septum midline, no sinus tenderness Throat-mucosa pink, pharynx no exudates, dentition good |
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Pulmonary
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Thorax symmetric with good expansion. Lungs resonant. Breath sounds vesicular. No rales, rhonchi, or wheezes. Diaphragmatic descent 4 cm.
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CV
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JVP 3cm above midsternal angle w head raised 30 degrees. Carotid upstroke brisk w no bruits. S1/S2 normal. No extra heart sounds, murmurs, or rubs. Chest nontender.
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Abdomen
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Abdomen flat w normal audible bowel sounds. No masses or hepatosplenomegaly felt. Kidneys not palpable. No CVA tenderness. Liver span 7cm in right midclavicular line. Liver border feels smooth 1cm below right costal margin.
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Neuromuscular
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Pt is A and O x3. CN 1 not tested. CN II-XII normal. RAMS normal F->N, H->S normal. Gait normal. Sensation to light touch, prick, and vibration normal in upper and lower extremities. Biceps and quadriceps muscles 5/5 muslce strength and good bulk and tone. Biceps and patellar tendon reflexes 2+. Romberg test normal. No pronator drift
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