Skin

Skin is consistent in pigmentation with an even amount of freckles across the bilateral upper and
lower extremities. There are no moles, macules, lesions, bruising, scratches, striae, or
discoloration present upon inspection. The skin is warm and dry upon palpation with an even
amount of thickness noted. Skin turgor is elastic. There is no odor present and appears to be in
good hygiene. No new or changing moles have been reported by the patient at this time.

Nails
All nails are clean and in good hygiene with a rounded edge. No clubbing, blood, broken, or
ridged areas are noted in or around nails. Hair growth is noted around digits indicating good
perfusion to the extremities. Capillary refill is less than 3 seconds on both bilateral upper
extremities.

Hair
Hair is light brown and evenly distributed across, scalp, eye brows, and eye lashes with no
missing patches noted upon inspection. Patient reports no recent hair loss noted. The scalp is
clean and moist with the skin intact. No mites, bumps, redness, flaking, or lesions are present.
The scalp is oily with no dry patches upon palpation.

Head & Neck

The head is normocephalic, non-tender, and atraumatic with light brown shiny hair that is evenly
distributed across scalp. Skull is normal in shape without any notable depressions. The hair is
clean and scalp is oily. No dandruff, mites, or lesions are present. The thyroid is not enlarged
upon palpation. Trachea is mid-lined and there are no masses or lesions. No lymphadenopathy is
present. No muscle spasms or tics noted. No bruits are present upon auscultation of the carotid
pulses, temporal pulses, or thyroid gland. Both carotid and temporal arteries are 2+ bilaterally.
No crepitus is palpated over the temporomandibular joint. Patient is able to perform ROM of
head and neck without limitation or pain.

Eyes
PERRLA. Right pupil 4mm and left pupil 4mm. Vision is 20/20 with both eyes. Pupils are
symmetrical with direct and consensual light reflexes. Discs appear normal upon examination.
Eyes are clear with no lesions, trauma, edema, or discharge noted. No ptosis, tremors, nodules,
edema, or lesions are noted on eyelids and patient is able to open/close without issue.
Conjunctivae and sclera are clear, moist, and free of foreign bodies. Lacrimal gland moist and
clear. All extra-ocular muscles all present. Lenses are clear and red flex is present bilaterally.
Patient reports no visual disturbances or changes at this time.

Ears, Nose, Throat

External ears are normal and free of cerumen with no tenderness, lesions, discharge, or nodules
noted upon inspection and palpation. Tympanic membranes are translucent, pearly gray and
 intact bilaterally. Patient responds appropriately to interview questions, is able to repeat the
correct words during whisper test, and answer correctly in regard to the tuning fork exam. Nose
is midline with no lesions, discharge, edema, tenderness, masses, or cartilage displacement.
Nares are patent bilaterally. Nasal mucosa is moist and pink. Septum is align. Frontal and
maxillary sinuses are non-tender and free of edema. The lips are pink, symmetric, and free of
edema. Gingivae and buccal mucosa are moist, pink, intact, and free of lesions. Teeth are intact
and in good repair. Tongue is symmetric, moist, and pink. Uvula, hard palate, and soft palate are
intact with no ulcerations. Tonsils are 1+ with no edema or lesions. No pharyngeal irritation. Gag
reflex present.

Respiratory
No deformities are noted upon inspection of the lateral, posterior, and anterior chest wall.
Lateral/AP diameter 2:1. Respirations are easy, unlabored, with no nasal flaring, retractions, or
use of accessory muscles. Respiratory excursion symmetrical. Respiratory rate of 18 breaths per
minute. No clubbing. There is no tenderness upon palpation of the chest wall or of the CTA. No
fremitus, crepitus, muscle spasms, or grating vibrations upon palpation. Resonance noted upon
percussion to bilateral anterior, posterior, and lateral chest. Clear breath sounds are noted upon
auscultation to bilateral anterior, posterior, and lateral lobes of the chest wall. No adventitious
breath sounds are noted. No hoarseness or cracking of the voice when speaking. Diaphragmatic
excursion measures approximately 4cm.

Cardiac
Pulse is 65 beats per minute with a regular rate and rhythm. No JVD. Carotid pulses are 2+
bilaterally upon palpation and regular. No bruits. PMI is not palpable. No heaves or thrills
present upon palpation of the chest. There are no murmurs, gallops, or rubs are present upon
auscultation. S1 > S2 at the apex and S2 > S1 at the base. No S3, S4, or murmurs present during
auscultation.

Peripheral Vascular
Bilateral upper and lower extremities are warm and dry to touch without any visible varicosities
or tenderness. Capillary refill is less than 2 seconds bilaterally. All pulses are 2+ with a regular
rate bilaterally and include: carotid, temporal, brachial, radial, popliteal, dorsalis pedis, posterior
tiblialis, and femoral. No bruits noted in peripheral pulses or abdominal aorta. Good elastic skin
turgor noted. No edema is present in bilateral upper and lower extremities.

Breast & Axillae

Breasts are symmetrical with no dimpling, retractions or drainage noted upon inspection. No
discolorations of the breast or areolas present. No lumps, nodules, or lesions are noted upon
light, medium, and deep palpation of the bilateral breast and axillae. No lumps, nodules, or
tenderness noted throughout tail of spence in bilateral axillae. Education provided on self-breast
exams given at this time. No lymphadenopathy noted.
 Abdomen
Abdomen is flat, non-distended with no visible hernias or masses upon inspection. Even
contraction of abdominal muscles noted when patient is instructed to lift head. Soft, with no
tenderness or masses noted upon light and deep palpation of the abdomen. No rebound
tenderness noted. Spleen, liver, and kidneys are non-palpable. Liver span 7 cm mid-clavicular
line. Negative Murphy’s sign. Tympany heard predominantly present upon all four quadrants of
the abdomen upon percussion. Bowel sounds present in all four quadrants of the abdomen upon
auscultation. No bruits heard over the aortic, renal, and femoral arteries.

Musculoskeletal
Full range of motion (ROM) noted for head, neck, spine, hips, and bilateral upper and lower
extremities. Muscle strength is 5+ in head, neck, bilateral upper and lower extremities. There is
no pain, tenderness, inflammation, nodules, or crepitus noted in joints. No edema, cyanosis, or
erythema. The spine is midline with a normal C curvature. Gait, balance and coordination are
intact.
Neurological
Patient is alert and oriented to person, place, and time. Good judgment, abstract thinking, recent
and remote memory intact. Cognitive functioning and 1-12 cranial nerves (CN) intact. Paitne
able to identify “berries” as the scent provided for CN 1 test. Bilateral 2+ deep tendon reflexes
(DTR) noted in biceps, triceps, brachioradialis, abdominal, patella, ankles, and plantar.
Appropriate balance noted upon performing Romberg test. Appropriate posture and gait noted
during movement on normal, toes, heels, and tandem walking with even strides. Sensation
proprioception is normal bilaterally. Vibratory response present and even over all joints in
bilateral upper and lower extremities. Appropriate perception noted and patient is able to identify
all familiar objects presented. No ankle clonus noted.
Female Genitalia & Anus
Pubic hair is present without any lost patches. Bilateral labia majora and minora are symmetrical
with no redness, swelling, tenderness, excoriation, rashes, lesions, discoloration, stretching,
varicosities, scarring, or trauma noted upon inspection and palpation. Labia minora are moist,
soft, homogeneous, and without tenderness. No discharge or ulcers noted. Clitoris is appropriate
in size with no atrophy, adhesions, or inflammation. No discharge, polyps, carbuncles, fistulae,
irritation, inflammation, or dilation of the urethral orifice. Vaginal introitus is moist with no
swelling, discoloration, discharge, lesions, fissures, or fistulae. No masses, tenderness, or
swelling of Bartholin glands and skene. Muscle tone us appropriate with no uterine prolapse or
urinary incontinence. Perineum is non-tender. Vaginal walls, cervix, uterus, ovaries, adnexal
areas are smooth with no redness, or lesions upon palpation. There is no discoloration, lumps,
fissures, lesions, skin tags, or scarring present on the anus. Appropriate sphincter tone noted. No
masses, lesions, strictures, or tenderness noted upon palpation of the anterior and posterior walls
of the rectum.