Vitals BP 130/80 HR 85 Temp 98.7 RR 12 O2 97%
General Well developed, well nourished, In no acute distress.
HEENT Head is normocephalic. Eyes PERRL, Conjunctiva are clear, Sclera are clear, EOMs intact. Ears show negative lesions on external inspection. Canals are clear, and TM pearly grey and translucent, landmarks intact. Oropharynx is clear with negative exudates, and neg tonsillar enlargement.
Pulmonary Non-labored, lungs clear to auscultation bilaterally, Equal chest expansion
Cardiac Regular Rate and Rhythm without murmurs, gallops or rubs, Neg Peripheral edema
Abdomen Soft and nontender in all quadrants. Bowel sounds active, Neg CVA Tenderness
Musculoskeletal Full use of UE and LE, Strength intact
Neurologic Alert and oriented, conversant. Cranial nerves intact, Strength is 5/5 in the UE and LE, Sensation intact.
Psychiatric Normal affect, Good judgement. Neg memory deficit.
Skin Clean and dry, negative discoloration, no rashes or lesions present