PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/76, pulse 78, respirations 16, temperature 98.8, and O2 sat 100% on room air.
GENERAL: This is a well-developed, well-nourished male, in no acute distress.
HEENT: Normocephalic and atraumatic. PERRLA, EOMI. TMs are intact with good light reflex. On oral examination, the patient does have poor dentition. He does have evidence of a tooth fracture down to the gum line of his left upper, what appears to be third molar. There is hypertrophy of the gingiva. There is no fluctuance, erythema, or edema noted to the area. Posterior oropharynx is pink and moist without erythema or exudate. Uvula is midline. Soft palate rises symmetrically.
NECK: Supple. No lymphadenopathy.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.2, pulse 106, respirations 20, blood pressure 142/90, and pulse ox 97% on room air.
GENERAL: This is a morbidly obese (XX)-year-old Hispanic female patient who is awake and alert, sitting on the gurney, resting comfortably, nontoxic.
HEENT: The head is normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. The right canal has pain with manipulation of the tragus and the pinna. The canal is edematous, unable to visualize the TM secondary to edema. In the left ear, the canal is clear without erythema, edema or discharge. TM is intact, pearly gray, sharp cone of light. There is no pain with manipulation of the pinna or the tragus.
NECK: Supple without meningismus. No lymphadenopathy noted.
LUNGS: Clear to auscultation, equal breath sounds bilaterally. No wheezes, rales, rhonchi, crackles or stridor noted. Respiratory excursion is symmetrical.
ABDOMEN: Soft, nontender, nondistended, positive bowel sounds all four quadrants. No guarding or rebound noted.
EXTREMITIES: On examination of the right knee, there is no erythema, edema or ecchymosis noted. The patient has point tenderness on the lateral and anterior portions of the knee. She complains of increased pain with range of motion and weightbearing. She denies numbness or tingling. Range of motion is limited secondary to pain. She has a good pedal pulse, brisk capillary refill, no obvious deformities, no crepitus noted.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure is 106/68, pulse 74, respirations 18, pulse ox 97% on room air, and temperature 98.4.
GENERAL: The patient is an otherwise healthy, well-developed, well-nourished (XX)-year-old female who is alert and oriented x3, nontoxic, in no apparent distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. The patient has no nystagmus. Ears: No tragal, mastoid or pinna tenderness. Canals/ears essentially normal. Nares patent. Oropharynx reveals bilateral tonsillar adenopathy and exudate with a slightly bilateral enlarged palate. His uvula is midline; it is not shifted or deviated, it is not edematous. He has no hot potato voice. He is not drooling. He has no trismus, no stridor.
NECK: Supple without anterior cervical lymphadenopathy.
LUNGS: Clear to auscultation, all fields. There is no evidence of distress.
HEART: Reveals normal sinus rhythm, no rubs or gallops.
ABDOMEN: Soft, nondistended, and nontender.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 97.4, pulse 78, respirations 18, O2 sat 99% on room air, and BP 130/86.
HEENT: The patient has just some slight scleral erythema. He is noted to have some cobblestoning of the inferior conjunctivae. The patient’s pupils are 2-3 mm equal, round, and reactive. There is no evidence of any drainage from his eyes at this time. His TMs are clear. His nares show some clear rhinorrhea.
CHEST: No retractions.
LUNGS: Clear with good equal breath sounds.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Soft, nondistended. Positive bowel sounds, nontender.
SKIN: No evidence of rash.
PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the emergency department today, temperature is 98.8. Blood pressure is 172/110; on manual recheck, it is 154/108. Pulse 100, respiratory rate 22, and O2 saturations 96% on room air. Visual acuity is 20/25 in the right eye and 20/30 in the left eye.
GENERAL: This is a (XX)-year-old well-developed, well-nourished Asian male in no acute distress. He is awake, alert, and oriented x3. He is pleasant and cooperative with the exam.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. His extraocular muscles are intact. He does not have any consensual photophobia or pain with accommodation. He is noted to have significant conjunctival injection bilaterally, right greater than left, with clear tearing to each eye. He also has some yellowish-appearing drainage from the right eye. There is no periorbital edema or evidence for cellulitis. No hordeolum appreciable and no foreign bodies appreciable. The globes appear to be intact.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 134/88, pulse 132, respirations 18, temperature 101.2, and pulse ox on room air is 93%.
GENERAL: This is a well-developed, well-nourished Hispanic male in no acute distress. He is alert and oriented x3 and does not appear postictal.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist. Ears are clear with no hemotympanum. The patient does have a large, deep 3-4 cm laceration noted to the right dorsal tongue, which appears old. There is some fibrinous exudate appreciated here as well as some purulent drainage. He does also appear to have scarring noted to the lateral aspects of the tongue from repetitive biting. He is handling his secretions well.
NECK: Supple without lymphadenopathy.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
ABDOMEN: Soft, nondistended, and nontender.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: Otherwise, warm, dry, and intact.
MUSCULOSKELETAL: There is no C, T, L, S midline tenderness. He moves all four extremities equally and ambulates without difficulty.
NEUROLOGIC: Cranial nerves II-XII are tested and intact. He has full 5/5 strength with resisted movement in all muscle groups of the upper and lower extremities. Sensation is intact throughout to light touch. There are no focal neurologic deficits.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/70, pulse 86, respirations 18, temperature 97.2 degrees, and pulse ox on room air is 97%.
GENERAL: This is a well-developed, well-nourished Asian female, in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist.
NECK: Supple.
CHEST: Respirations are easy and unlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
EXTREMITIES: No cyanosis, edema or clubbing.
SKIN: The patient has scattered areas of confluent erythematous papules noted to the left face, more mildly to the right face, left neck, and right lower abdomen. There are no vesicles noted. These are not distributed in a linear fashion; however, it does appear consistent with a contact dermatitis. She also has a few scattered excoriated macules noted to the right posterior calf with no evidence of secondary cellulitis. These appear consistent with mosquito bites, as reported by the patent. There is no burrowing noted. Palms and soles are spared. No involvement of the oral mucosa. No evidence of secondary bacterial infection. Skin is otherwise warm, dry, and intact.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/80, pulse 72, respiratory rate 18, temperature 97.8, and O2 sat 99%.
GENERAL: The patient did not appear toxic or ill.
HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are fully intact. Oropharynx is clear. No erythema. Uvula is midline. Tonsils are not inflamed. No submandibular, sublingual or buccal space swelling. No difficulty tolerating her secretions. No hoarseness or stridor.
LYMPHATIC: No lymphadenopathy.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, no cyanosis, and no edema.
SKIN: Warm, dry, and intact.
PSYCHIATRIC: Alert and oriented x4.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/88, pulse rate 94, respirations 24, temperature 98.2, and O2 sat 97%
GENERAL: The patient is alert and oriented x4, in no acute distress, does not appear toxic or ill, is uncomfortable.
HEENT: After the pain was controlled, we were able to get a better exam, which showed pupils to be equal, round, and reactive to light. Extraocular muscles were fully intact. The patient denies having any hyphema or hypopyon. The patient did not have any corneal abrasions. Ocular pressures by Tono-Pen were 18 on the right and 16 on the left.
NECK: The patient has full range of motion of the neck without any pain. She has no meningismus, no nuchal rigidity. Negative Brudzinski. Negative Kernig.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended, positive bowel sounds.
EXTREMITIES: No clubbing, no cyanosis, no edema.
SKIN: Warm, dry, and intact.
PSYCHIATRIC: Alert and oriented x4.
LYMPHATICS: No lymphadenopathy.
VASCULAR: Good pulses throughout all four extremities.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.4, pulse 82, respiratory rate 18, blood pressure 128/88, and pulse ox 97% on room air.
GENERAL: This is a well-appearing Hispanic gentleman in no acute distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. His conjunctivae and sclerae are severely injected. The lids are inverted demonstrating no foreign body. His extraocular muscles are intact. His periorbital areas are puffy, but no erythema, fluctuance, induration or pain to palpation. He had tenderness over his TMJs bilaterally with palpable swollen rubbery lymphadenopathy that was tender to palpation. His TMs were clear bilaterally. No erythema, effusions or exudate. He had some shotty lymphadenopathy in his anterior cervical chain. He did not have evidence of trismus. He had normal occlusion. He did not have tenderness when biting on a tongue blade, and we were able to break a tongue blade between his teeth. His uvula was midline. His palate was symmetrical. He did not have any ulcers or lesions in his mouth.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds.
EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or edema.
NEUROLOGIC: Awake, alert, and oriented x4. His motor and sensory was grossly intact.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 94/60, pulse 96, respirations 18, temperature 98, and O2 sat is 97%.
GENERAL: The patient is alert and oriented x3, in no acute distress, nontoxic in appearance, ambulatory in the emergency department.
HEENT: Normocephalic and atraumatic. PERRLA, EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucosa moist and pink. No sinus tenderness noted.
NECK: Supple without lymphadenopathy. No spinous process tenderness of the C-spine.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Positive bowel sounds in all four quadrants, soft, nontender.
EXTREMITIES: She has 2+ pulses in all extremities. The patient does have some ecchymosis noted to her bilateral lower extremities. There is no tenderness to palpation of the patellae bilaterally. Negative valgus, negative varus, negative Lachman, negative drawer sign. Full range of motion of all extremities. No edema, erythema, warmth to touch or deformity noted.
BACK: Negative CVA tenderness. No spinous process tenderness of the cervical, thoracic, and lumbosacral spines.
SKIN: Warm and dry to touch.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/76, temperature is 97, pulse 88, and respirations 18. The patient’s pulse oximetry is 97% on room air.
GENERAL: The patient is a (XX)-year-old male, in no acute distress, A&O x3.
HEENT: Head is normocephalic and atraumatic. There is no facial swelling. No erythema or warmth on exam. Eyes: EOMs intact bilaterally. Pupils are equal, round, and react to light. Ears: TMs and canals are clear. Nares are patent. Pharynx patent. Oral mucosa pink and moist. Dental examination reveals tenderness with palpation and percussion over the left maxillary lateral incisor, which is obviously decayed. There is no evidence of any periodontal abscess. There is no facial swelling. No erythema or warmth on exam. No trismus.
NECK: Supple. No lymphadenopathy. Good full range of motion of the cervical spine.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation in all lung fields.
SKIN: Natural in color. Capillary refill is brisk. There is no exanthem.
