History and Physical //

INITIAL VITAL SIGNS: Reviewed by me GENERAL: Awake, alert and oriented x 4, well appearing, non toxic, speaking in full sentences. HEAD: Atraumatic. Normocephalic. EYES: EOMI. PERRL. No discharge. No conjunctival injection. Atraumatic external ears and nose. ENT: Moist mucous membranes NECK: Supple. No masses. Full range of motion. No meningismus. RESPIRATORY: Clear to auscultation bilaterally. Good tidal volume. No wheezing, crackles, or rhonchi. No accessory muscle use. CV: Regular rate and rhythm. No murmurs, rubs, or gallops. Equal pulses x 4. ABDOMEN: Soft, non-distended, non-tender. No guarding. No rebound. EXTREMITIES: No clubbing or cyanosis. No edema. No obvious deformity. SKIN: Warm and dry. No rash, lesions, or petechiae. NEUROLOGIC: Normal mental status and speech. Face is symmetric. Moves all extremities equally. Sensation intact diffusely. Normal coordination. Ambulates with a strong steady gait.



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