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Normal findings

Terms in this set (14)

Hello Dr. Wagner, The presentation will be on your patient Terry Dayton, Cis-gender male, that is 30 years old, with no pertinent past medical history
Intro
The head, face, and neck are symmetrical without skin lesions or deformities. Pupils are equal, round, reactive to light and accommodation. Extra ocular muscle movements are intact. Visual acuity is 20/20 OS, OD, OU.
HEENT
The external auditory canals are patent, and the tympanic membranes are intact with clear anterior cone of light reflexes. Hearing is normal bilaterally and symmetrical with the "finger rub" test.
Hearing
The external auditory canals are patent, and the tympanic membranes are intact with clear anterior cone of light reflexes. Hearing is normal bilaterally and symmetrical with the "finger rub" test.
Hearing
The nares are patent, the nasal mucosa is pink and moist, there are no septal defects noted. The oropharynx is clear. The uvula is midline. The mucosa is pink and moist. The tonsils are not enlarged and have no exudates. The dentition is in good repair.
Nose and throat
There is no lymphadenopathy. The thyroid is symmetrical without nodules or enlargement.
Lymph
The thorax and spine are symmetrical, with no lesions, deformities, or use of accessory muscles. The chest wall is non-tender to palpation and rib motion is without restriction or asymmetry. Cardiac auscultation reveals the heart to be regular rate and rhythm, with a normal S1 and S2.
INTEGRATED THORAX
The lungs are clear to auscultation bilaterally anteriorly and posteriorly. Thoracic excursion is full and without restrictions.
Lungs
There are no temperature abnormalities, tissue texture changes, or asymmetry of transverse processes. This is no tenderness or segmental restriction of motion. There is full active range of motion in cervical, thoracic and lumbar spines. Given the absence of significant abnormal findings, I would forego making a segmental diagnosis.
Tart & Spine
The abdomen (flat/round/scaphoid), and symmetrical without skin lesions or scars. The abdomen is not distended. Bowel sounds are present and normoactive.
Abdomen
There is no visceral drag. Palpation reveals the abdomen is soft, non-tender without guarding, no hepatomegaly, and no masses. There is no restriction of motion with the ASIS compression test. There is no CVA tenderness.
Drag
On inspection and palpation of the UE and LE, there are no trophic changes, lesions, discoloration, deformities, hypertrophy, atrophy, tenderness or other tissue texture changes. UE and LE pulses are 2+ and brisk, there is no pitting edema noted. Muscle tone is normal.
NEURO/MSK
Strength is 5/5 bilaterally in the UE and LE. There is full range of motion for all UE and LE motions tested. The lateral malleolus, greater trochanter, head of the humerus and the external auditory meatus are in line with each other.
Strength to line
On forward bending, there is no scoliosis, peaks, valleys or flattening of the spinal curve. The patient is able to perform normal gait, toe, heel and tandem walking without difficulty. Temperature and light touch sensation are intact in the UE and LE in the C5, C6, C8, L4, L5 and S1 dermatomes. Deep tendon reflexes are 2+/4+ bilaterally in the biceps, triceps, brachialis, quadriceps and achilles.
Ending of neuro
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