Thursday, November 13, 2008

PHYSICAL EXAMINATION - Normal values.

BP 120/80 125/84 T 98.6 Wt. 150
P 68/reg 70/reg R 14/nm. Ht. 5110H
General: Well-developed, well-nourished male, appearing stated age, no acute distress.
Skin & Hair: Warm, dry, with good turgor, No abnormal pigmentation, rash, or other lesions. Hair normal texture and distributon.
Head: Normocephalic without scalp lesions. No facial asymmetry. No sinus tenderness. No parotid or submaxillary gland enlargement or tenderness.
Eyes: No en- or exophthalmos, strabismus, or nystagmus. No ptosis, edema, or lesions of lids. No lid lag. Conjunctivae and sclerae moist without jaundice or suffusion. Cornea and anterior chamber clear. Pupils equal round, react to light and accommodation. (PERRLA)Fundi-Disc margins sharp with physiologic cupping. A/V ratio 2/3 with sharp vessel crossings. Macula clear. No hemorrhages or exudates.
Ears: No external tenderness or lesions of pinnae. Canals patent without inflammation. Tympanic membranes intact with normal light reflex and landmarks.
Nose: No deformity. Nares patent. Mucous membranes pink without discharge, hypertrophy, polyps, or other lesions. No septal deviation.
Mouth and Throat: Lips without lesions. Mucous membranes pink without inflammation or lesions. Tongue normal size and papillation. Tonsils absent. Good dental hygiene. Gingiva pink without hypertrophy.
Neck: Supple with full range of motion. No masses or tenderness. Jugular veins fill to posterior border of SCM at 30 degrees. Trachea midline. Thyroid not palpable.
Lymph Nodes: No anterior or posterior cervical, occipital, supraclavicular, axillary, epitrochlear, inguinal, or popliteal nodes palpable.
Chest & Lungs: Respiratory excursions full and symmetrical. No increase in A-P diameter. Normal tactile fremitus). Lungs resonant to percussion. Vesicular breath sounds throughout peripheral lung fields. Vocal fremitus normal. No rales, ronchi, wheezes, or rubs.

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