Slightly somber affect at first, then brighter later. Skin
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. HEENT
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs
intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive
light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds.
Pulses 3+ throughout. No edema. Respiratory
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. Gastrointestinal
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. Genitourinary
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal
distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized.
A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink
and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness.
No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is
smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). Musculoskeletal
Full ROM seen in all 4 extremities as patient moved about the exam room. Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal. Psychiatric
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though
clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Urinalysis – pending
Urine culture – pending
Wet prep – pending
Special Tests
Diagnosis
Differential Diagnoses
o 1- o 2- o 3-
Diagnosis
o
Plan/Therapeutics
