Normal Documentation

Head

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

Neck

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

Vitals

Temperature (C or F), pulse (bpm), respirations (rpm), blood pressure (S/DBP), height (in, cm), weight (kg or lb), BMI (calculated)

General

Patient is a well-developed, well-nourished AGE year old (race/ethnicity if relevant) M/F in no apparent distress

Chest/Lungs

Thorax symmetrical and nontender to palpation. respirations regular and unlabored without retractions. chest wall non-tender to palpation. percussion: resonance is normal in all lung fields. Clear to auscultation to bases bilaterally, no wheezes, rales or rhonchi

Abdomen

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

Neuro

A&0X3, 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).

Skin

No lesions or rashes, temperature, turgor and texture are WNL. Nails without deformity, no clubbing or cyanosis

Eyes

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

Ears

Auricles symmetrical without deformities. Canals patent, tympanic membranes 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.

Cardiovascular

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

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 and 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.