Normal Female Examination
From OpenEMR Project Wiki
PMH, medications, allergies, FH, SH and ROS were reviewed.
Vital signs were reviewed.
EYES: The eyelids are normal and there is no scleral icterus. The pupils are round and equally reactive to light. The fundi are normal with no evidence of hemorrhages, microaneurysms or exudates. There are no cotton wool spots. There is no copper wiring or arteriolar narrowing.
MOUTH, EARS and NOSE: The tympanic membranes are pearly gray. The nasal mucosa is pink with no discharge. The oropharynx is pink with no tonsillar erythema or exudate. There was no evidence of abnormal masses or leukoplakia.
NECK: There is no adenopathy. There are no bruits. There is no JVD. There is no thyromegaly.
RESPIRATORY: The breath sounds are equal bilaterally with normal amplitude. There are no crackles, rubs, or wheezes. There is no tactile fremitus. There is no dullness to percussion.
CHEST: The breasts are free of abnormal masses. There is no nipple discharge or retraction. There is no skin retraction. The axillae are free of adenopathy.
CARDIOVASCULAR: The heart sounds are normal. There are no murmurs, rubs, clicks or gallops. The radial pulses are 2/4 and symmetric. The femoral pulses are 2/4 and symmetric with no evidence of bruits. The posterior tibial pulses and dorsalis pedis pulses are 2/4 and symmetric. The aorta has no mass and no audible bruits.
ABDOMEN: There is no abdominal tenderness. The bowel sounds are normal. There are no abdominal bruits. There is no hepatosplenomegaly. There are no palpable masses.
GROIN: There is no adenopathy. There are no masses. There are no direct or indirect hernias palpated.
RECTAL: There are no rectal masses and the stool is hemoccult negative.
GU: The external genitalia are normal. There are no adnexal masses or tenderness. The cervix is closed with no motion tenderness. The uterus is a small lemon size without tenderness.
SKIN: There is no focal abnormal thickening, rash or mass.
EXTREMITIES: The hands are pink with no evidence of cyanosis. The legs are normal with no evidence of edema or varicosities. The feet are pink with normal capillary refill and no cyanosis.
MUSCULOSKELETAL: There is no swelling, erythema or warmth of the joints of the fingers, wrists, elbows, shoulders, knees, ankles and toes. There is no tenderness of the cervical, thoracic or lumbar spine.
NEUROLOGICAL: The cranial nerves 2/12 were normal. The motor examination is 5/5 and symmetric. The deep tendon reflexes are 2/4 and symmetric.
Samuel T. Bowen, MD