100 0604
- YouTube
100 0604
22 yo WM. Smoker, 3 cigarettes/day x 3yrs. ETOH, 5 beers/wk. No recreational drug use stated. Has no present complaints. Hx: No medical illneses, tonsilectomy in 2006. Family history, mother sarcoma cancer in 2009, father HA 1996, 2009, CABG x4, 1996. All in good health. Has sibling, no health issues. Vital signs: BP-115/72, P-74, T-98.4F, RR-16. Pain 0/10 Hand hygeine perfomed befor entering room. Explained procedure for health assesment. Nice looking young man, clean no odor, Head normo-cephalic, symmetrical, appropriate bony prominences. Hair brown, clean, and thick Scalp is clean, no lesions, flaking or masses noted, Eyes are symmetrical, outer canthi is even with pinnae. Billateral pupil response, PRRLA, 3mm right eye, 2mm. in left. Movement followed in all 6 cardinal fields of gaze. 20/20 vision noted both eyes using Snellen chart. Symmetrical reflexion of cornae. Lens are clear. Eye lashes are everted, brow line is even. Eyes are moist, no drainage or signs of infection, sclerae are white. Connjuntiva are pink, no crusting. Auricles are movable, non-tender. Tragus and mastoid areas are non-tender, with no swelling noted. Whisper and Weber tests were unremarkable. Face is symmetrical exept for nasal diviation. Nares show slightly deviated septum there is no obstruction foreign objects or mucus present. Membranes are pink and moist. Lips are moist, even, and free of lesions/masses. Teeth are straight, white, clean, 27 are noted (Patient was born w/out wisdom teeth ...
YouTube | September 24, 2011
