The patient did respond appropriately to painful stimuli in all four extremities. PHYSICAL EXAMINATION: General: Normal appearance, in no acute distress. The thyroid is normal to palpation. No ulcerations or rashes noted. SKIN: Warm and dry. Strength and sensation are grossly intact. Positive bowel sounds. Lungs: Breath sounds are clear bilaterally without rales, rhonchi or wheezing. Noninjected sclerae. HEENT: Pupils are round and reactive to light, pink conjunctivae. If you need professional help with completing any kind of homework, Success Essays is the right place to get it. LUNGS: Rare basilar crackle bilaterally. Cranial Nerve Exam: Pupils are equal and reactive at 3 mm and brisk. No peritoneal signs are present. Oropharynx is clear with pink, moist mucous membranes. The patient’s vitals are also noted. Extraocular muscles are intact. NEUROLOGIC: Intact, moving all 4 extremities symmetrically and spontaneously and is following commands. Nasal septum and whether turbinates are enlarged or reddened, sinus tenderness to palpation and percussion. Nose: Nasal turbinates are erythematous and edematous with clear nasal drainage. Her speech has decreased fluency, is hypophonic, and not fully appropriate. GENERAL APPEARANCE: The patient is alert, oriented and has a bandage over his left eye. EXTREMITIES: Lower extremities are without clubbing. Both pupils are equal, reactive to light and accommodation. Her blood pressure was 142/72, pulse is 78, respirations 20, and temperature is 97.4. Pupils were equally reactive to light. Nasal septum is midline. The patient is noted to have skin tags around the neck. Head: eyes and ears aligned, normocephalic, atraumatic, non-tender to palpation throughout, except left frontal area. Abdomen: No tenderness. Her body habitus is ectomorphic and she is markedly asthenic. DP pulses +2 in bilateral extremities. She has a better-than-average fund of knowledge. The left pupil has an eccentric shape but is approximately equal in size to the right and reactive both directly and consensually. Neurologic is nonfocal. Plantar responses are downgoing bilaterally. The patient has flexor digitorum profundus as well as flexor carpi ulnaris and abductor digiti minimi as well as flexor digiti minimi and all digits including the adductor pollicis. Deep tendon reflexes: These are very brisk and 3+ everywhere, except at the ankles, where they are trace. The patient has mild bradyphrenia and also frequently gets off topic and has some difficulty answering questions clearly. PHYSICAL EXAMINATION: External auditory canal and tympanic membranes. This website uses cookies to improve your experience while you navigate through the website. She has a poor fund of knowledge. ABDOMEN: Bowel sounds are present. Face is symmetric. BACK: Straight without midline defect. Both TMs and canals are occluded with cerumen. Other commonly used med words that bug the sh1t out of me:-Punky. Thyroid: Not palpable. Oropharynx reveals poor dentition but is clear without lesions. The patient is afebrile. Conjunctivae and EOM are normal. HEENT: Head is normocephalic. NEUROLOGIC: Cranial nerves II through XII are grossly intact. The uvula is midline. No murmur. VITAL SIGNS: T-max was 100, currently 97.5, blood pressure 110/60, respirations 22, and heart rate 88. When she walks with me, she has a quite ataxic gait and clearly has difficulties visually scanning her environment. PHYSICAL EXAMINATION: ABDOMEN: There is no pain, no tenderness, no distention and no organomegaly. The oropharynx is clear. Sclerae nonicteric. • NCAT = normocephalic, atraumatic • PERRL = Pupils Equal Round and Reactive to Light • Erythema = redness • Exudate (tonsilar) = most commonly white spots on the tonsils, but can be any fluid or cellular matter deposited on any tissue • Purulent = consisting of pus • … Tone is normal. There is no gross facial asymmetry. NEUROLOGICAL: Appears to move all extremities and this exam is only pertinent for confusion at this time. She does have bilaterally enlarged tonsils, which she states is baseline for her, but no difficulty or pain with swallowing. Oropharynx is clear. Eye: Symmetrical OU; no redness, no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Ankle and foot exam was normal. Hearing is intact to conversational tone. EXTREMITIES: No clubbing, cyanosis or edema with vascular changes of bilateral lower extremities. Sensation intact to pinprick, light touch, vibration and proprioception. NEUROLOGIC: Cranial nerves II through XII intact. Coordination: Intact finger-to-nose testing with no dysmetria. These cookies will be stored in your browser only with your consent. There is no surrounding cellulitis. Her blood pressure is on the low side at 100/72. This category only includes cookies that ensures basic functionalities and security features of the website. No peripheral edema. There was no new abnormality. No wheezes, rales or rhonchi. No intraabdominal masses, hepatic or splenic enlargement. Extraocular movement intact. No wheezing, rales or rhonchi. EOMs intact bilaterally, no nystagmus. CENTRAL NERVOUS SYSTEM: Nonfocal. No conjunctival injection is noted. PHYSICAL EXAMINATION:
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