EYES: Patient denies any problems associated with vision, does not wear any form of corrective lenses but does not remember her last vision test. Patient denies any pain, redness/swelling, watering/discharge, or allergies that affect her eyes. No history of trauma or surgery associated with eyes, no history of glaucoma. Patient is a student nurse and uses protective eyewear when suspecting possible contact with human secretions, with no episodes of exposure while working.
EARS: Patient denies earache, infections, discharge, hearing loss, tinnitus or vertigo. Patient reports daily use of Q-tip, cotton swabs to clean ears. Does not remember last hearing examination.
NOSE: Patient denies any discharge or congestion in the nose. Denies any allergies, frequent upper respiratory infections, sinus pain, nosebleeds, changes in sense of smell, and no trauma to nose.
MOUTH AND THROAT: Patient denies sores, lesions, gum bleeding, toothaches, loose teeth, difficulty swallowing, changes in sense of taste, hoarseness, or sore throat. Patient denies use of any tobacco products and reports drinking about 3 drinks/week in a social setting. Reports twice daily teeth brushing; sees dentist twice a year for cleaning. No dentures or dental appliances.
AXILLA: Patient denies tenderness, lumps, rashes, irritation, or pain.
THORAX, LUNGS: Patient denies cough, dyspnea, or chest pain while breathing. No history of respiratory infections. Denies use of any tobacco products and no smoking. Last TB test in May 2012, seasonal flu/H1N1 shot in October 2012, and no pneumonia immunization. Patient is a nursing student and takes necessary precautions (fitted-mask, PPE, masking patient, patient in private room, etc) when working with patients with respiratory issues or who are on airborne or droplet precautions.
GENERAL SURVEY: Patient is alert and oriented x3 and appears healthy today with a steady gait and no acute distress. Well-dressed in casual clothing; good hygiene. Patient was cooperative throughout examination. Able and willing to answer questions.
HEAD: Normocephalic with no deformities, lumps, or tenderness. Scalp is free of scales, lesions, dryness, or redness. TMJ free to movement with no crepitus or tenderness. Face is symmetrical with no dropping or weakness, uniform pigmentation, no edema, no involuntary movements, and no masses.
EYES: Eyebrows symmetrical, hair evenly distributed with no patches of hair missing, no scaling or lesions. Eyelids intact with no redness, edema, discharge or lesions. Palpebral fissure open with no lesions. Eyelashes evenly distributed. Conjunctiva are clear with no edema, lesions, or pallor. Sclera is white. Lacrimal apparatus is free of erythema, tearing, and swelling. Corneas are clear of opacities, scars, or lesions. Irises are dark brown with uniform coloration, round shape. PERRLA, 4mm in size, and symmetric. Vision is 20/20 uncorrected, full visual field by confrontation bilaterally and no deviations or defects observed.
EARS: Auricles are symmetrical with no swelling, lesions, deformities, or lumps. No piercings present. Tragus is firm with no tenderness reported upon palpation. No pain or tenderness on palpation of mastoid process. External auditory meatus have no swelling, discharge, or discoloration, no cerumen observed. Weber test shows no lateralization. Positive Rinne test with AC > BC bilaterally. Whispered “baseball” heard bilaterally.
NOSE AND SINUSES: Nose is symmetrical and midline with no deformities, tenderness, deviations, inflammation, or lesions. Nostrils are patent bilaterally with no observed obstructions. Nasal mucosa is moist, red, and smooth with no swelling, discharge, bleeding, or foreign objects. Turbinates same color as mucosa with no poylps or swelling. Nasal septum is midline with no deviation, inflammation or perforation. Frontal, maxillary and ethmoid sinuses nontender on palpation.
MOUTH AND PHARYNX: Lips are pink, moist and symmetrical with no lesions or cracking. Gums pink with stippled surface, no redness, swelling, bleeding. Teeth are uniformly white in color, straight and evenly spaced, with upper incisors slightly override lower incisors when teeth are clenched. No missing, loose, or broken teeth. Dorsal surface of tongue is pink and uniformly colored, free of nodules, lesions and ulcerations. Ventral surface of tongue is smooth, glistening, and shows veins. Saliva present, submandibular gland visible and patent. Buccal mucosa is pink, smooth, moist. Stensen’s duct is visible and patent. Hard palate white with irregular transverse rugae. Soft palate pink and smooth. Uvula is pink, midline, and moves with phonation. Tonsils are pink, size 0, symmetrical, with no exudate and no swelling. Posterior pharynx is pink and free of erythema, swelling, and exudate.
NECK: Free of bulges, masses, scars, swelling, and pulsations with no JVD observed. Neck is centered at midline; accessory muscles are symmetric, full ROM with no pain or limitations. Trachea is midline with no deviation. Thyroid is symmetric, with no enlargement, nodules, or tenderness.
LYMPH NODES: Preauricular, posterior auricular, occipital, submental, submandibular, tonsillar, superficial cervical, deep cervical chain, posterior cervical chain, and supraclavicular lymph nodes all nonpalpable and nontender. Central, lateral, anterior, and posterior lymph nodes of axxilary/arm region all nonpalpable, nontender.
THORAX AND LUNGS: Skin warm, tan-pink, dry, and intact with uniform pigmentation, and no peripheral cyanosis, capillary refill
University/College: University of Chicago
Type of paper: Thesis/Dissertation Chapter
Date: 25 December 2016
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