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SKIN: warm to touch, brown, dry, with good skin turgor, body hair is
short and scanty, nails are pink with normal fold, with petechial rash on both lower extremeties
EYES: The patient has thin, black eyebrows evenly distributed, normal
palpebral fissure, no lid edema, no ptosis, negative lid lag test, normally set eye balls, thin black eyelashes, directed outward, no matting, pale palpebral conjunctiva, white sclera, transparent cornea, black iris with regular contour, pupils normal in size and shape equally reactive to light and pupils constrict and eyes adduct during accommodation, transparent lens, positive ROR reflex.
with pinkish walls, with scanty brownish materials, tympanic membranes are pearly white and intact with visible cone of light. No visible mass or deformities, No discharges and no bleeding
ORAL CAVITY: Lips are dry. Buccal mucosa and gums are pink with no
signs of swelling, Tongue is normal in size, located at midline, and symmetrical. Hard and soft palates are pink, no lesions; uvula is in the midline, tonsils are not enlarged, slightly hyperemic pharyngeal wall.
HEART: External jugular veins are visible and palpable, jugular Venous
Pressure is 5 cmH20, carotid arteries are palpable, strong, regular with equal pulsations and soft consistency of walls, precordium is flat, apex beat is located on the 4th ICS 1-2cm from the LMCL, 2 cm in diameter, adynamic, no thrusts, heaves and thrills, cardiac rate is _____ with regular rhythm, no extra heart sounds, bruit and heart murmurs. Nails of extremities are pink, no deformities and lesions, popliteal, femoral, radial and brachial arteries are normal, regular with equal pulsations and soft consistency of walls.
NEUROLOGIC EXAM:
Cranial Nerves:
I: can identify smell of coffee II: pupils 2-3mm,equally reactive to light III, IV, VI:full and equal extra ocular muscles V: can clench teeth equally, (+) corneal reflex VII: no facial asymmetry VIII: can hear clicking of pen IX, X: (+) gag reflex XI: can turn head on both sides against resistance XII: tongue in the midline
Motor Function:
5/5 5/5 5/5 5/5
Sensory Function:
100% 100% 100% 100%
Meningeal irritation: (-) nuchal rigidity, (-) Brudzinski sign, (-) Kernig sign Pathologic Reflexes: (-) Babinski, Right (-) Babinski, Left, (-) ankle
clonus