7 Personal and Social History Smoker – 2.5 pack yearsOccasional alcoholic beverage drinkerNo illicit drug use
8 Review of Systems General: No weight loss Skin: No itchiness, no jaundiceEyes: No blurring of vision, eye pain or itchiness, no excessive lacrimation, no rednessEar: No deafness, no discharge, no tinnitusNose: No epistaxis, dischargeThroat: No sore throatMouth: No bleeding gums, no oral soresNeck: No neck stiffness, no massesCardiac: No chest pain, no palpitationsAbdominal: No abdominal pain, no diarrhea, no vomitingMusculoskeletal: No myalgia, arthralgiaEndo: (-) polyuria, (-) polyphagia, (-) polydipsia; no heat/cold intoleranceNeuro: No seizure, no headachePsychiatric: no depression
9 Physical ExaminationConscious, coherent, ambulatory, not in cardiorespiratory distressBP 100/70 mmHg PR 84, regular RR 20 cpm, T 37.0°CWarm dry skin, no active dermatoses, no jaundicePink palpebral conjunctiva, anicteric sclerae
10 Physical ExaminationNo nasoaural discharge, turbinates not congested, moist buccal mucosa, nonhyperemic posterior pharyngeal wallSupple neck, (-) palpable cervical lymph nodes, no masses, no tendernessSymmetrical chest expansion, unimpaired transmission of tactile fremiti, resonant on percussion, clear and equal breath sounds
11 Physical ExaminationAdynamic precordium, AB 5th LICS MCL, S1>S2 at apex, S2>S1 at base, no murmurs, no S3 or S4, no heaves, no lifts, no thrillsFlabby abdomen, normoactive bowel sounds, palpable liver edge, liver span 17cm R MCL, palpable spleen, 15cm below subcostal area, 2.5 cm past midline, tenderness on palpation of hypogastric area, no CVA tendernessDRE: Prostate enlarged, smooth, no nodulesPulses full and equal, no cyanosis, no clubbing, no edema
12 Neurologic Examination Awake, alert, follows commands, oriented to person, place, timePupils 2-3mm, ERTL, (+) direct and consensual reflex intact, EOMs full and equal, no ptosis, V1V2V3 intact, (+) corneal reflex, can clench teeth can raise eyebrows equally, can close eyes against resistance , can smile, can frown, can puff cheeks, no facial asymmetry, intact gross hearing, can shrug shoulders and can turn head side to side against resistance, (+) gag reflex, tongue midline on protrusionMotor: 5/5 on both UE and LE; no tremors, no fasciculations, no atrophyCerebellar: Can do APST/ FTNT with easeDTRs ++ on both UE and LENo sensory deficit(-) Babinski, (-) nuchal rigidity
Your consent to our cookies if you continue to use this website.