Exam

Inspect skin overall: Skin is warm and dry with no lesions seen

Inspect hair color, distribution, thickness: Thickness and distribution pattern typical for patient gender

and age

Inspect nails: Nails without ridging, pitting, or peeling.

Test capillary refill, fingers: Normal

Inspect neck: No visible scars, deformities or other lesions. Trachea midline and freely mobile. No

asymmetry or accessory respiratory muscle use with quiet breathing

Palpate neck: Full cervical range of motion. No meningeal signs. Thyroid WNL for size and consistency, no

palpable nodules. No cervical lymphadenopathy.

JVP: normal

Palpate all lymph nodes: Two right supraclavicular nodes, each approximately 2 cm in diameters, firm,

nonmobile, nontender. No cervical, axillary, infraclavicular, or inguinal lymphadenopathy.

Visual inspection- anterior and posterior chest: The chest is symmetrical and the anterior-posterior (AP)

diameter is normal. The excursion with respiration is symmetrical and there are not abnormal

retractions or use of accessory muscles. No distention, scars, masses or rashes.

Percuss- anterior and posterior chest: The anterior lung fields are resonant. The left anterior ches (heart)

and right lower chest (liver) are dull to percussion. The rest of the lung fields are resonant and are not

hyper-resonant.

Palpate AP chest: No tenderness, lumps or masses. Normal tactile fremitus. All superficial thoracic lymph

nodes are non-palpable or of normal size and consistency.

Auscultate lungs: L Lung normal, R Lung expiratory wheezes in upper lobe anteriorly and posteriorly

Auscultate heart: Normal

Visual inspection of abdomen: Abdomen is flat and symmetric with no scars, deformities, striae or

lesions.

Auscultate abdomen: Normal

Palpate abdomen: No pain, tenderness, masses or pulsations. No guarding or rebound tenderness. No

hepatosplenomegaly. Liver span normal. The spleen is not palpable.

Percuss abdomen: No tympany or shifting dullness.

Visual inspection of extremities: Atraumatic, no joint swelling, no signs of DVT, no peripheral edema.

Inspect palpate head: Normocephalic, atraumatic

Ocular motor: normal

Pupils: normal reactive

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