words per minute
16
DRMOHAMED_ALI
00:00
Speed
General: Well appearing, well nourished, in no distress. Oriented x 3, normal mood and affect .
Ambulating without difficulty.
Skin: Good turgor, no rash, unusual bruising or prominent lesions
Hair: Normal texture and distribution.
Nails: Normal color, no deformities
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi
have normal optic discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant
resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia
Back: Spine normal without deformity or tenderness, no CVA tenderness
Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses
intact
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal
strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal
in upper and lower extremities. No pathologic reflexes.
Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, normal mood
and affect.
Pelvic: Vagina and cervix without lesions or discharge. Uterus and adnexa/parametria nontender
without masses.
Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or
supraclavicular adenopathy.
G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes
and epididymides normal size without masses, scrotum without lesions.