GENERAL SURVEY

Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and cheerful. Height is 5′4″, weight
135 lbs, BMI 24, BP 120/80, right and left arms, HR 72 and regular, RR 16, temperature 37.5°C.”

The patient is alert, well-groomed, and cheerful. Speech is fluent and words are clear. Thought
processes are coherent, insight is good. The patient is oriented to person, place, and time. Serial 7s
accurate; recent and remote memory intact. Calculations intact.

SKIN

“Skin warm and dry. Nails without clubbing or cyanosis. Approximately 20 brown, round macules on
upper back, chest, and arms, are all symmetric in pigmentation, none suspicious. No rash, petechiae, or
ecchymoses.”

HEENT

Head—The skull is normocephalic/atraumatic (NC/AT). Hair with average texture.

Eyes—Visual acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Pupils are 4 mm constricting to 2
mm, equally round and reactive to light and accommodations. Disc margins sharp; no hemorrhages or
exudates, no arteriolar narrowing.

Ears—Acuity good to whispered voice. Tympanic membranes (TMs) with good cone of light. Weber
midline. AC > BC. Nose—Nasal mucosa pink, septum midline; no sinus tenderness.

Throat (or Mouth)—Oral mucosa pink, dentition good, pharynx without exudates.

Neck—Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt.

Lymph Nodes—No cervical, axillary, epitrochlear, inguinal adenopathy

THORAX AND LUNGS

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles,
wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.

CARDIOVASCULAR SYSTEM

The JVP is 3 cm above the sternal angle with the head of bed elevated to 30°. Carotid upstrokes are
brisk, without bruits. The PMI is tapping, 1 cm lateral to the midclavicular line in the 5th intercostal
space. Crisp S1 and S2. At the base, S2 is louder than S1 with physiologic split of A2 > P2. At the apex, S1
is louder than S2. There are no murmurs or extra sounds.

BREAST

Breasts symmetric and smooth without nodules or masses. Nipples without discharge.

ABDOMEN
Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable masses or
hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm
below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.

PERIPHERAL VASCULAR

Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and
nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and
posterior tibial (PT) pulses are 2+ and symmetric.

MALE GENITALIA

Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended
bilaterally, smooth, without masses. Epididymis is nontender. No inguinal or femoral hernias.

FEMALE GENITALIA

No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal mucosa pink.
Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No
adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses. Stool
brown and negative for fecal blood.”

ANUS RECTUM AND PROSTATE

No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate
smooth and nontender with palpable median sulcus. (Or in a female, uterine cervix nontender.) Stool
brown; no fecal blood.

MUSCULOSKELETAL

Full range of motion in all joints of the upper and lower extremities. No evidence of swelling or
deformity.

NERVOUS SYSTEM

Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place,
and time. Detailed cognitive testing deferred.

Cranial Nerves:

Cranial Nerves:

I—not tested;

II—visual acuity intact; visual fields

full;

III, IV, VI—extraocular movements intact;

V motor—temporal and masseter strength intact, corneal reflexes present;

VII
motor— right and left facial movements intact,

sensory—

taste not tested;

VIII—hearing intact bilaterally to whispered voice;

IX, X—gag intact;

XI—strength of sternocleidomastoid and trapezius muscles 5/5;

XII—tongue midline

Motor: Good muscle bulk and tone. Strength 5/5 throughout.

Cerebellar—Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S) intact. Gait
with normal base. Romberg—maintains balance with eyes closed. No pronator drift.

Sensory: Pinprick, light touch, position, and vibration intact.

Reflexes: 2 and symmetric with plantar reflexes downgoing