Skin, hair, and nails: No report of problems with skin, hair, or nails. Head and neck: Denies headaches, swelling, stiffness of neck, difficulty swallowing, sore throat, enlarged lymph nodes. Eyes: Reports that she wears glasses for reading. Denies eye infections, redness, excessive tearing, halos around lights, blurring, loss of side vision, moving black spots/specks in visual fields, flashing lights, double vision, and eye pain. Ears: Denies hearing loss, ringing or buzzing, earaches, drainage from ears, dizziness, exposure to loud noises. Mouth, throat, nose, and sinuses: Client reports missing upper molars. Denies bleeding of gums or other dental problems; sore throats; mouth lesions; hoarseness; rhinorrhea; nasal obstruction; frequent colds; sneezing or itching of eyes, ears, nose, or throat; nose bleeds; snoring. Thorax and lungs: Denies difficulty breathing, wheezing, pain, shortness of breath during routine activity, orthopnea, hemoptysis, respiratory infections. Reports dry to productive cough of clear sputum in morning upon waking. Breasts and regional lymphatics: Denies lumps or discharge from nipples, dimpling, or changes in breast size. Denies swollen or tender lymph nodes in axilla. Heart and neck vessels: Client reports last blood pressure was 130/84. Denies chest pain or pressure, palpitations. Peripheral vascular: Denies edema of legs or feet, pain, cramping, lesions on legs, color or texture changes of legs or feet. Abdomen: Describes lack of appetite (see 24-hour dietary recall). Denies difficulty swallowing, nausea, vomiting, gas, jaundice, hernias. Musculoskeletal: Denies erythema, pain, or stiffness of joints. Denies weakness. Reports ability to perform activities of daily living (ADLs) without difficulty. Neurologic: See COLDSPA. Denies feelings of anger or suicidal thoughts. Denies concussions, headaches, loss of strength or sensation, lack of coordination, difficulty speaking, memory problems, strange thoughts and/or actions. Female genitalia: Denies sexual problems; sexually transmitted infections (STIs); dribbling or incontinence. Menarche age 13. Menopause at age 51. Denies pelvic pain, use of oral contraceptives, and use of hormone replacement therapy (HRT). Anus, rectum, and prostate: Reports having a daily bowel movement of formed brown stool. Denies pain with defecation, hemorrhoids, blood in stool, constipation, and diarrhea.
General Survey Ht: 5 foot 1 inches; Wt: 127 lb; Radial pulse: 68; Resp: 18; B/P: R arm—132/76, L arm—128/72; Temp: 98.6. Client alert and cooperative. Sitting comfortably on table with arms at sides. Dress is neat and clean. Walks steadily, with posture erect. Mental Status Examination: Pleasant and friendly. Appropriately dressed for weather with matching colors and patterns. Clothes neat and clean. Facial expressions symmetric and correlate with mood and topic discussed. Speech clear and appropriate. Tearful as she discusses her husband and his accident. Carefully chooses words to convey feelings and ideas. Oriented to person, place, time, and events. Remains attentive and able to focus on examination during entire interaction. Short-term memory is deficient, long-term memory is intact. General information questions answered correctly 100% of the time. Vocabulary suitable to educational level. Explains proverb accurately. Gives semiabstract answers. Is able to identify similarities 5 seconds after being asked. Answers to judgment questions in realistic manner. Skin, Hair, Nails Skin: Light brown, warm and dry to touch. Skinfold returns to place after 1 s when lifted over clavicle. No evidence of vascular or pruritus lesions. Hair: Straight, clean, black with white and gray streaks, thick and supple in texture. No scalp lesions or flaking. No hair noted on axilla or on chest, back, or face. Nails: Fingernails short in length and thickness, clear. No clubbing or Beau’s lines. Head and Neck Head symmetrically rounded, neck nontender with full ROM. Neck symmetric without masses, scars, pulsations. Lymph nodes nonpalpable. Trachea in midline. Thyroid nonpalpable. Eyes Eyes 2 cm apart without protrusion. Eyebrows thick with equal distribution. Lids light brown without ptosis, edema, or lesions, and freely closeable bilaterally. Lacrimal apparatus nonedematous. Sclera white without increased vascularity or lesions noted. Palpebral and bulbar conjunctiva slightly reddened without lesions noted. Iris uniformly brown. PERRLA, EOMs intact bilaterally. Ears Auricles without deformity, lumps, or lesions. Auricles and mastoid processes nontender. Bilateral auditory canals clear. Tympanic membranes pearly gray bilaterally with visible landmarks. Hearing intact with Whisper test bilaterally. Mouth, Throat, Nose, and Sinuses Lips moist, no lesions or ulcerations. Buccal mucosa pink and moist with patchy areas of dark pigment on ventral surface of tongue, gums, and floor of mouth. No ulcers or nodules. Gums pink and moist without inflammation, bleeding, or discoloration. Hard and soft palates smooth without lesions or masses. Tongue midline when protruded, no lesions, or masses. No lesions, discolorations, or ulcerations on floor of mouth, oral mucosa, or gums. Uvula in midline and elevates on phonation. External structure of nose without deformity, asymmetry, or inflammation. Nares patent. Turbinates and middle meatus pale pink, without swelling, exudate, lesions, or bleeding. Nasal septum midline without bleeding, perforation, or deviation. Frontal and maxillary sinuses nontender. Thorax and Lung Skin light brown without scars, pulsations, or lesions. No hair noted. Thorax expands evenly bilaterally without retractions or bulging. Respirations even, unlabored, and regular. No tenderness, crepitus, or masses. Tactile fremitus equal and symmetric bilaterally. Vesicular breath sounds heard throughout. No crackles, wheezes, or friction rubs. Heart and Neck Vessels No pulsations visible. No heaves, lifts, or vibrations. Apical impulse: 5th ICS to LMCL. Clear, brief heart sounds throughout. S1, S2 present. No S3, S4, gallops, murmurs, or rubs. Abdomen Abdomen rounded, symmetric without masses, lesions, pulsations, or peristalsis noted. Abdomen free of hair, bruising, and increased vasculature. Umbilicus in midline, without herniation, swelling or discoloration. Bowel sounds low pitched and gurgling at 16/min × 4 quads. Aortic, renal, and iliac arteries auscultated without bruit. No venous hums or friction rubs auscultated over liver or spleen. Tympany percussed throughout. No tenderness or masses noted with light and deep palpation. Liver and spleen nonpalpable. Peripheral Vascular Upper Extremities: Equal in size and symmetry bilaterally; light brown; warm and dry to touch without edema, bruising, or lesions. Radial pulses = in rate and 2+ bilaterally. Brachial pulses equal and 2+ bilaterally. Lower Extremities: Legs symmetric. Skin intact, light brown; warm and dry to touch without edema, bruising, lesions, or increased vascularity. Femoral pulses 2+ and equal without bruits. Dorsalis pedal and posterior tibial pulses 1+ and equal. No edema palpable. Musculoskeletal Posture erect. Gait steady, smooth, and coordinated with even base. Full ROM of cervical and lumbar spine. Full ROM of upper and lower extremities. Strength 5/5 of upper and lower extremities. Neurologic Cranial Nerve Examination: Cranial nerves II through XII grossly intact. Motor and Cerebellar Examination: Muscle tone firm at rest, abdominal muscles slightly relaxed. Muscle size adequate for age. No fasciculations or involuntary movements noted. Gross and fine motor movements intact. Romberg: Minimal swaying. Tandem walk: Steady. No involuntary movements noted. Sensory Status Examination: Superficial light and deep touch sensation intact on arms, hands, fingers, legs, feet, and toes. Position sense of toes and fingers intact bilaterally. Stereognosis and graphesthesia intact.