Escolar Documentos
Profissional Documentos
Cultura Documentos
Mental Status: The patient is alert, well:groomed, and cheerful. Speech is fluent and words are clear.
Thought processes are coherent, insight is good. The patient is oriented to person, place, and time. Serial 7s
accurate; recent and remote memory intact. Calculations intact.
OR
Mental Status: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are
mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is
oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed.
Clock drawing is good.
Skin warm and dry. Nails without clubbing or cyanosis. Approximately 20 brown, round macules on upper
back, chest, and arms, are all symmetric in pigmentation, none suspicious. No rash, petechiae, or
ecchymoses.
OR
Marked facial pallor, and circumoral cyanosis. Palms cold and moist. Cyanosis in nail beds of fingers and
toes. Numerous palpable purpura on lower legs bilaterally.
OR
Scattered stuck-on verrucous plaques on back and abdomen. Over 30 small round brown macules with
symmetric pigmentation on back, chest, and arms. Single 1.2 1.6 cm asymmetric dark brown and black
plaque with erythematous, uneven border, on left upper arm.
OR
Facial plethora. Skin icteric. Many telangiectatic mats on chest and abdomen. Single 5 mm pearly papule
with rolled border on left zygomatic cheek. Nails with clubbing but no cyanosis.
Recording the Physical Examination: The Head, Eyes, Ears, Nose, and Throat (HEENT)
HEENT: HeadThe skull is normocephalic/atraumatic (NC/AT). Hair with average texture. EyesVisual
acuity 20/20 bilaterally. Sclera white, conjunctiva pink. Pupils are 4 mm constricting to 2 mm, equally round
and reactive to light and accommodations. Disc margins sharp; no hemorrhages or exudates, no arteriolar
narrowing. EarsAcuity good to whispered voice. Tympanic membranes (TMs) with good cone of light.
Weber midline. AC > BC. NoseNasal mucosa pink, septum midline; no sinus tenderness. Throat (or
Mouth)Oral mucosa pink, dentition good, pharynx without exudates.
NeckTrachea midline. Neck supple; thyroid isthmus palpable, lobes not felt.
Lymph NodesNo cervical, axillary, epitrochlear, inguinal adenopathy.
OR
HeadThe skull is normocephalic/atraumatic. Frontal balding. EyesVisual acuity 20/100 bilaterally.
Sclera white; conjunctiva injected. Pupils constrict 3 mm to 2 mm, equally round and reactive to light and
accommodation. Disc margins sharp; no hemorrhages or exudates. Arteriolar-to-venous ratio (AV ratio) 2:4;
no AV nicking. EarsAcuity diminished to whispered voice; intact to spoken voice. TMs clear. Nose
Mucosa swollen with erythema and clear drainage. Septum midline. Tender over maxillary sinuses. Throat
Oral mucosa pink, dental caries in lower molars, pharynx erythematous, no exudates.
NeckTrachea midline. Neck supple; thyroid isthmus midline, lobes palpable but not enlarged.
Lymph NodesSubmandibular and anterior cervical lymph nodes tender, 1 cm 1 cm, rubbery and
mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy.