General: Danny Rivera is a calm, cooperative, and pleasant Puerto Rican-American male who is

alert and oriented to person, place, time and situation. The patient was brought into the clinic by
grandmother and the patient is the primary source of information. Patient appears well-developed
and well-nourished. Patient is fatigued and maintains eye contact throughout the interview and
examination. Patient seats upright on the examination table. He is no acute distress despite
coughing every few minutes. Speech is clear and coherent and speaks in full sentences. Good
historian.
Vitals: (SEE DOCUMENT AT HOME)
Skin: intact, no lesions or rashes noted. Turgor is good. There is no cyanosis, pallor or jaundice.
HEENT: Head: normocephalic, atraumatic. Eyes: Pupils equal and reactive to light. No ptosis,
eyelid edema, lesions, allergic shiners. Sclera white, conjunctiva moist and pink bilaterally. No
conjunctiva discharge present. Ears: right ear canal color is pink. Right tympanic membrane is
erythemic with inflammation. Right ear cone of light is 5:00. No discharge noted in the right ear.
No fluid, visible scars, bulging, perforation and retraction noted on the right tympanic
membrane. Left ear canal color is pink with a pearly gray tympanic membrane. No fluid, visible
scars, bulging, perforation and retraction noted on the left tympanic membrane. Left ear cone of
light is 7:00. No discharge noted in the left ear. Bilaterally ear canals are patent. Nose: nares
patent bilaterally. No polyps noted. Nasal mucosa pink with clear discharge. Turbinates patent.
No foreign body present, septum deviation, lesions, and perforation noted. Throat: oral mucosa
pink and moist. Tonsils erythemic and inflamed. Posterior oropharynx erythemic with
cobblestoning. No post-nasal drip noted. No frontal and maxillary tenderness reported bilaterally.
Buccal mucosa intact without lesions. Dentition is good and gums are pink, not inflamed.
Neck: symmetrical, full ROM, right palpable cervical nodes noted. No palpable supraclavicular
and axillary nodes noted. No carotid bruits. No tracheal deviation.
Respiratory: chest symmetrical with respirations, no wheezing, crackles, or other adventitious
lung sounds.
Cardiovascular:
Breasts:
Abdomen:
Genitalia:
Rectal:
Musculoskeletal:
Neurological:
Motor: