OBJECTIVE: The patient rests comfortably and does not appear to be in any apparent distress.















GENERAL APPEARANCE: Looks well; in no distress; pleasant and cooperative; talkative; thin; heavyset; obese;


HEAD: symmetric; without deformity, masses, or tenderness


EYES: adnexae are benign; conjunctivae are without erythema or discharge; sclera are white; pupils are equal, round, reactive to light and accommodation; extra-ocular muscles are intact; fundus is benign, with cup:disc ratio of 0.3, A:V ratio of 2:3, and no hemorrhages, exudates, or papilledema


EARS: external auditory canals and tragi are non-tender; tympanic membranes are transparent, mid-position, and mobile


NOSE: straight; without deformity; mucosa is pinkish-red and not edematous; nasal airway is patent


THROAT: pharynx is pink and moist, without erythema, exudate, or tonsillar enlargement; there are no oral mucosal lesions; teeth are in good repair


NECK: neck is supple; without masses, deformity or tenderness; carotid pulses are full and equal; no carotid bruits; thyroid is not palpably enlarged; no thyromegaly; no cervical or supraclavicular lymphadenopathy; trachea is midline


CHEST: symmetric, without deformity or tenderness; respiratory excursion is equal bilaterally


BREASTS: without skin changes, masses, nipple discharge, or axillary adenopathy


LUNGS: good air movement bilaterally; lungs are clear to auscultation, without crackles or wheezes


HEART: regular rate and rhythm, with normal first and second heart sounds; S2 physiologically split; no murmurs rub, or gallops; apical impulse is in the midclavicular line in the left fifth intercostal space; there is no jugular venous distension or hepatojugular reflux


ABDOMEN: soft, flat, nontender, without masses or organomegaly; no abdominal bruits; no scars


GENITOURINARY: testes are both descended and without masses; penis is uncircumcised and without discharge; there are no inguinal bulges


PELVIC: external genitalia are benign; speculum exam reveals pink and ruggated vaginal mucosa without discharge; cervix is non-parous, with benign mucosa; bimanual exam reveals a small, nontender uterus that is anteverted; there are no adnexal masses or tenderness


MUSCULOSKELETAL: extremities are symmetric and without deformity; joints are without tenderness, erythema, warmth, effusions, or synovial thickening, and they have full range of motion; there is no cyanosis, digital clubbing, or edema; back is straight, with full range of motion in all planes


SKIN: there are no rashes or suspicious lesions


NEUROLOGICAL: Cranial Nerves: visual acuity is 20/20 bilaterally; visual fields are intact to confrontation; pupils are equal, round, reactive to light and accommodation; facial sensation is intact bilaterally; facial muscle strength is 5/5 bilaterally; auditory acuity is grossly intact; gag reflex is intact; palate rises symmetrically and tongue extends in midline; trapezius strength is 5/5 bilaterally Sensory: sharp-dull discrimination, vibratory sense, and proprioception are intact in all extremities; two- point discrimination is less than 5mm in both hands; Motor: extremity strength is 5/5 and symmetric in all extremities; there is no pronator drift Reflexes: biceps, triceps, brachioradialis, patellar, and Achilles reflexes are all 2/4 and symmetric; toes are downgoing bilaterally; (or you can draw a stick figure patient and write1-4, as appropriate, at each reflex) Cerebellar: Rhomberg is negative; finger-to-nose, heel-to-shin, and rapid alternating movements are normal; there is no ataxia or dysmetria; gait is stable and fluid; tandem walk is normal forward and backward