PC2 Normal PE

Cc

“Work physical”

Vital Signs

Temperature 97 F, Pulse 70bpm, Respirations 14rpm, Blood Pressure 120/80, Height 65in, Weight 126lbs, BMI 21

General

Patient is a well-developed, well-nourished 28 year-old caucasian female, cooperative and in no apparent distress.

Skin

No lesions or rashes, temperature, turgor and texture are within normal limits (WNL). Nails without deformity, no clubbing or cyanosis.

Head

Normocephalic, atraumatic (NC/AT). Scalp without lesions or masses. Hair texture, pattern and distribution are within normal limits (WNL).

Eyes

Eye lids without swelling or lesions. Near vision visual acuity = 20/20 OS, OD & OU, uncorrected. Sclera white and anicteric. Conjunctiva clear, without pallor. Pupils equally round and reactive to light and accommodation (PERRLA). Fundi - red reflex present bilaterally. No A-V nicking, hemorrhage, exudates, or papilledema. EOMI

Ears

Auricles symmetrical without deformities. Canals patent, tympanic membranes (TMs) pearly gray bilaterally, light reflex/landmarks intact. Hearing grossly intact to whispered voice bilaterally.

Nose

Nose without asymmetry or deformity. Nasal mucosa pink, septum midline, without perforations. Turbinates non-edematous. No nasal discharge, nares patent bilaterally.

Mouth/Throat

Lips, tongue and oral mucosa without lesions. Teeth/gums in good repair. Posterior pharynx pink, 1+ tonsils bilaterally without erythema or exudates.

Neck

Supple, symmetrical without fullness, masses, JVD, or thyroid enlargement. No cervical lymphadenopathy. No carotid bruits.

Chest/Lungs

Thorax symmetrical and nontender to palpation. Respirations regular and unlabored without retractions. Chest wall nontender to palpation. Percussion: resonant is normal in all lung fields. Clear to auscultation (CTA) to bases bilaterally, no wheezes, rales, or rhonchi.

Cardiovascular

Regular rate and rhythm (RRR) with no murmurs, gallops, clicks, or rubs. S1 and S2 within normal parameters (WNL), no S3 or S4. Radial, carotid, DP, and PT pulses 2+ and equal bilaterally.

Abdomen

Soft, non-tender, non-distended, no scars, normoactive bowel sounds (NABS). No palpable masses, no hepatosplenomegaly. No inguinal nodes or hernias.

Musculoskeletal

UE and LE Extremities symmetrical, no visible deformities. Symmetric and adequate muscle size and tone. UE and LE: Joints without tenderness, swelling, or stiffness. UE/LE full range of motion (FROM) equal and bilateral at shoulder, elbow, wrist, fingers, hips, knees, ankles, toes. Strength is 5/5 bilaterally at the deltoids, biceps, triceps, quadriceps, and hamstrings. Spine without bony tenderness or paraspinal muscle tenderness or masses from cervical to sacral. No SI joint pain to palpation. Full flexion, extension, lateral side bending and rotation intact.

Neurological

A&OX3, answers questions appropriately with clear and coherent speech. Appropriate affect and eye contact. Follows commands. No noted involuntary movements. CN II-XII grossly intact. Sensation intact in UE/LE to light touch. Sharp/dull differentiation intact in lower and upper extremities. DTR 2+ equal bilaterally at biceps, triceps, brachioradialis, patella, and Achilles. Vibratory and position senses intact bilaterally in the upper and lower extremities. Gait is steady with normal base. Intact heel-toe gait without abnormalities. Rapid alternating movements intact bilaterally (or heel to shin, or finger to nose), Rhomberg negative (or pronator drift)