Physical Exam

General: well-appearing man laying in a supine position in NAD

HEENT: Skull is normocephalic/atraumatic. Hair is average texture.

Eyes: Sclera white, conjunctiva pink. Pupils are 4mm constricting to

2mm, equally round and reactive to light and accomodations. Disc
margins sharp; no hemorrhages or exudates, no arteriolar narrowing.

Nose: Nasal mucosa pink, septum midline, no sinus tenderness

Throat: Oral mucosa pink, dentition good, pharynx without exudates

Neck: Trachea midline. Neck supple; thyroid isthmus palpable, lobes

not felt.

Lymph Nodes: No cervical, axillary, epitrochlear, inguinal adenopathy.

Cardiovascular Exam: The JVP is 3 cm above the sternal angle with

head of the bed elevated to 30 degrees. Carotid upstrokes are brisk,
without bruis. The PMI is tapping, 7 cm lateral to the midsternal line in
the 5th intercostal space. S1, S2, no murmurs, rubs, clicks or gallops.
No carotid or renal bruis. Capillary refill less than 2 seconds. Pulses 2+
bilaterally

Pulmonary Exam: Thorax is symmetric with good expansion. Lungs

resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi.
Diaphragms descend 4cm bilaterally.

Abdominal Exam: Abdomen is protuberant with active bowel sounds

in all four quandrants. It is soft and nontender; no masses or
hepatosplenomegaly. Liver Span is 7cm in the right midclavicular line;
edge is smooth and palpable 1 cm below the right costal margin.
Spleen and kidneys not felt. No costovertebral angle tenderness.

Extremities: Extremities are warm and without edema. No

varicosities or stasis changes. Calves are supple and nontender. No
femoral or abdominal bruits. Brachial, Radial, femoral, popliteal,
dorsalis pedis, and posterior tibial pulses are 2+ and symmetric.

Musculoskeletal: Good Range of motion in all joints. No evidence of

swelling or deformity.

Neurological Exam: Alert, relaxed, and cooperative. Oriented to

person, place, and time. Cranial Nerves II-XII intact.

Motor: Good muscle bulk and tone. Strength 5/5 throughout.

Cerebellar- rapid alternating movements, finger to nose, and heel to
shin intact.

Romberg- maintains balance with eyes closed. No pronator drift