Physical exam

General: Patient appears in mild distress from persistent cough and voice sounds congested. Appears fatigued. Adequate hygiene and posture; generally healthy for age except for recent illness.

HEENT:

Head and neck: Hair is evenly distributed over scalp, no alopecia or nits. Face and neck appear symmetrical. Skin is dry and intact except for mild errythema around the nasal folds, no drainage, crusting, or lesions visualized. No c/o pain/tenderness upon palpation of frontal and maxillary sinuses. No cervical lymphadenopathy palpated.

Eyes: Skin around is eyes pink, dry, and intact without edema. Conjunctiva pink and moist. Sclera white, capillaries intact. PERRLA.   Red reflex visualized bilaterally with ophthalmoscope; retinal background is yellow, capillaries are well-defined without evidence of hemorrhage; no bulging or cupping of optic disc visualized bilaterally.

Ears:   Skin is pink, dry, and intact without edema. Denies tenderness upon palpation. Ears visualized with otoscope; ear canals are pink, dry, and intact with mild cerumen; tympanic membranes are pearly gray, no bulging or discharge visualized.

Nose: Symmetrical, midline of patient's face. Skin slightly errythematous under folds. Nostrils patent bilaterally. Nasal mucosa and inferior turbinates errythematous, moist, and intact bilaterally. Mild amount of white nasal drainage visualized.

Mouth/ Throat: Lips are pink and mildly chapped. Oral mucosa, tongue, gums, and teeth intact. Posterior pharynx mildly errythematous with some cobblestoning; uvula is midline. No tonsillar edema visualized.

Lungs: Chest expansion symmetrical, respirations appeared unlabored and even. Intermittant moist cough followed by short periods of tachypnea. Resonance percussed over upper chest; area of dullness percussed over right lower lobe. Increased fremitus palpated in left lower lobe. BS are clear bilaterally in upper lobes. Expiratory wheezing, rales, and diminished BS auscultated   right lower lobe. BS clear and diminished in left lower lobe.

Heart: Heart rate and rhythm are regular. No murmurs, clicks, rubs, or adventitious sounds auscultated. Skin in all 4 extremities is pink, warm, dry, and intact.

 

 

 

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