Читать книгу The Family Nurse Practitioner - Группа авторов - Страница 55

Vital signs: BP: 132/80 (L) sitting; P: 78; RR: 10; weight: 152 lbs; height: 5 ft 7 inches; BMI: 23.8.

General: Appears well; in no apparent distress; neatly dressed; appropriate affect.

HEENT: Head: Nontender; without masses; hair thinning slightly in some areas. Eyes: Clear conjunctivae; PERRLA intact; EOMI; fundi sharp optic discs; normal retinal arterioles; no A‐V nicking. Ears: Clear external auditory canals; TMs + light reflex and landmarks visible; hearing grossly normal. Mouth/Throat: + normal mucosa, tongue, pharynx, and tonsils; dentition in good repair.

Neck: Supple, without lymphadenopathy. Thyroid nontender, without palpable masses or enlargement. Carotids without bruits.

Respiratory: Clear to auscultation and percussion, anterior and posterior; without wheezes, rales, or rhonchi.

Cardiac: RRR: normal S1 and S2 without murmurs, rubs, or gallops.

Breasts: Without masses, skin changes, or discharge bilaterally; no lymphadenopathy.

Abdomen: Soft, nondistended, nontender; + bowel sounds × 4 quadrants; without HSM, masses, or bruits.

Gynecological: Vaginal mucosa slightly dry, rugae present; uterus firm and anteverted, nontender, without palpable masses; adnexa nontender, without palpable masses bilaterally; no lesions noted.

Rectal: No lesions or masses noted; + external hemorrhoids; nontender; + normal sphincter tone.

Extremities: Without cyanosis, edema, or clubbing; +2 pulses bilaterally. + full range of motion throughout, nontender joints without crepitus.

Neurologic: CN II–XII grossly negative; 5/5 motor strength, gait even; DTRs 2+; Romberg negative.