Term
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Definition
| Appears well in no distress. Well nourished, groomed, developed. Cooperative |
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Term
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Definition
| P, BP, R, Temp (not taken) |
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Term
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Definition
| Normocephalic, atraumatic. Scalp free of lesion and tenderness, freely moveable, pink. Frontal and maxillary sinuses non-tender. No TMJ clicking. Facial features symmetrical. |
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Term
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Definition
| skin warm, pink, moist. No visible lesions or rashes over entire body. No alopecia, symmetrical, normal male/female distribution of body hair. Nails pink, smooth, uniform thickness, no clubbing, brisk capillary refill. |
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Term
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Definition
| extra ocular muscles intact, PERRLA, anicteric sclera, conjunctiva pink without discharge or lesions. Lids free of lesions. Lashes symmetric, evenly distributed. Red reflex intact bilaterally. No nystagmus or strabismus. No corneal abrasions or cataracts. Cornea and lens clear. Optic disc cream colored with well defined borders, macula free of lesions/discharge. A:V 3:5, no papilledema. Peripheral vision equal to examiners. Visual acuity measured by Rosenbaum eyechart 20/20L, 20/20R with or without corrective lenses. |
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Term
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Definition
| Pinna flexible, no lesions, deformities, tenderness. External auditory canals clear. Tympanic membrane intact, gray, translucent, light reflexes present bilaterally, bony land marks present bilaterally. Finger rub intact at 2 feet bilaterally. |
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Term
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Definition
| external nose free of deformities. Moist and pink mucous membranes bilaterally. Turbinates and septum free of lesions bilaterally. Septum midline. No discharge, no flaring. |
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Term
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Definition
| No external lesions, lips pink. Moist and pink mucous membranes. No lesions on buccal mucosa, on or under tongue. Good dentition. Tongue and uvula midline, soft palate intact. Tonsils 1+. Oral pharynx free of exudate and erethema. |
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Term
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Definition
| Trachea midline and mobile. Thyroid smooth and non-tender on palpation. No palpable a/p cervical, pre/post auricular, submandibular, submental, supraclavicular. |
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Term
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Definition
| AP diameter 2:1, respirations without accessory muscle, thoracic expansion symmetrical. Tactile fremitus symmetric. Lungs clear to auscultation and percussion bilaterally. CVA non-tender to percussion. No adventitious breath sounds. |
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Term
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Definition
No JVD, No thrills or heaves to inspection or palpation. PMI palpable at 5th intercostal, mid-clavicular line. Normal S1/S2, S1 coinciding with carotid pulse. No murmurs appreciated.
Pulses: regular in rhythm.
Carotid L/R 2+, Brachial L/R 2+, Radial L/R 2+, Femoral L/R 2+, Popliteal L/R +/-, Posterior Tibial L/R 2+, Doralis Pedis L/R 1+. No carotid, femoral, renal, abdominal aorta, iliac bruits. |
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Term
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Definition
| flat/round/scaphoid without scars, legions, trauma. Bowel sounds appreciated in all four quadrants. Tympanic to percussion over epigastric region, dull in remaining areas. Soft, non-tender, no masses, no organomegally appreciated on light/deep palpation. Liver span 7 cm. No superficial veins or telangictasia. |
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Term
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Definition
| no tenderness or enlargement in epitrochlear, axillary, cervical, inquinal areas. If Feel: shape, size, consistency, mobility (firm/nodular) |
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Term
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Definition
| Normal muscle bulk/tone. Joints- no warmth, non-tender to palpation. Normal/full ROM without crepitus. Strength 5/5 bilaterally |
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Term
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Definition
| oriented 3x. CNII-XII. V- light touch sensation appreciated bilaterally in all three divisions. Muscles of mastication 5/5 bilaterally. VII facial features symmetric bilaterally, able to squeeze eyes tightly, and muscles of facial expression 5/5. IX-X gag reflex intact. XI trapezius and SCM 5/5 bilaterally. XII tongue midline strength 5/5. Rhomberg -, normal gate with smooth and regular rhythm, babinski -, Reflexes: Brachioradialis, biceps, triceps, patellar, Achilles +2 |
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