VITAL SIGNS: WNL except for

GENERAL/ PSYCHIATRIC: Pt looks calm, collaborative, in no acute distress. Mood

and affect normal. Appears in general good health.

HEENT: NC/AT. Sclerae non icteric. EOM normal. PEERLA. Normal fundoscopy
bilaterally. External ears w/o lesions and no ear discharge. No canal erythema. TM
normal in both sides. Nares patent, nasal turbinates not congested. Mouth moist w/o
lesions or thrush. Tongue central , tonsils w/o exudates and no erythema or enlargement.
Good dentition.

NECK: Supple, non tender, no JVD. No thyromegaly, no lymphadenopathy. No carotid

bruit.

CHEST: No skin erythema, no deformities, no scars, cuts. No tenderness on palpation.

Symmetric and normal expansibility on bases / apex . No tactile fremitus . No dullness,
whisper pectorioquay or egophony. Respiratory sounds CTA, no rales, rhonchi or
wheezings. PMI non displaced, RRR- S1 S2 Normal no M/R/G. No JVD or HJR.
Pulses 2+ in all extremities. No pedal edema. No varicosities.

ABDOMEN: No masses or scars, Soft non tender, non distended, No ascitic wave or
visible pulsations . Murphy's sign negative. No rebound tenderness. R/L CVA no
tenderness. Psoas sign negative. Obturator sign negative. Rovsing sign negative. No
abdominal defense. Bowel sounds normal in all 4 quads.

MSK: ROM passive/ active joint above and joint below normal. Involve joint ROM
globally decreased . Sensation intact , motor strength 5/5 , maneuvers : Lhermite test -/+,
Brudzinsky +/-, Kernig +/-, R/L SLRT +/-

EXTREMITIES: No deformities, no trauma. No tenderness . No erythema, warmth or

swelling. ROM normal or decreased. Muscle strength 5/5 in all 4 limbs. DTR's 2+
bilaterally. Sensation intact to sharp and dull. No cyanosis, clubbing or edema.

NEUROLOGICAL: A,A , O x 3 . Good concentration and adequate feedback. CN 2-12

grossly intact. Sensation intact and symmetric ro sharp and dull stimuli in all 4 limbs.
Motor strength 5/5 in all muscles groups. DTR +2 intact & symmetric . Rapid
alternating hands movement intact. Romberg negative. Gait normal.
VITAL SIGNS: WNL except for ****

GENERAL: Pt looks anxious , restless but collaborative. Appears well nourished and
hydrated

HEENT: NC/AT. No head tenderness. Eyes aliegned, EOM normal, Sclerae non icteric.
PERRLA. Fundoscopy normal bilaterally. Nares patent, nasal turbinates non congested.
Mouth moist, tongue central w/o lesions , no thrush. Tonsils non enlarged, no erythema
or exudates. Good dentition

CHEST No skin erythema or lesions. No scars or wounds. No tenderness on palpation.

Normal expansibility in both bases and apex. Respiratory sounds CTA, no rales, rhonchi
or wheezing. No tactile fremitus, no egophony or whisper pectoriloquay. PMI non
visible non palpable, RRR S1 – S2 normal w/o M/R/G, Pulses symmetric +2 in all 4
limbs.

ABDOMEN: Soft non tender non distended w/o masses or scars. No visible pulsations.
No ascitic wave. Murphy sign negative, Psoas sign negative, Rovsing sign negative,
Obturator sign negative. No rebound tenderness. Bowel sounds present and normal in all
4 quads.

EXTREMITIES: No deformities, no scars. No tenderness . ROM decreased to active

and passive movements. Sensation intact to sharp and dull stimuli. Muscle strength 5/5
in all areas. DTR'S symmetric in all 4 limbs. No cyanosis, no edema. Pulses +2 bilateral
in all 4 limbs.

NEUROLOGICAL: A,A, O x 3 . Good concentration and adequate feedback during

examination. CN 2-12 grossly intact. Sensation intact to sharp and dull stimuli in all
arear. Motor strength 5/5 in all muscles groups. DTR's +2 intact & symmetric. Rapid
alternating hands movement intact. Romberg negative. Babinsky negative. Gait normal.