EXAMS - normal:
GENERAL: He appears alert & normally developed for his age.
EYES: Head exam is unremarkable. No scleral icterus or orbital trauma noted.
HEENT: Mucous membranes moist. Nares patent without copious rhinorrhea.
LUNGS: No cough and no respiratory distress.
CARDIAC: Rhythm is regular. No dysrhythmias or murmurs.
ABDOMEN: Nonsurgical with no peritoneal signs.
EXTREMITIES: Nonedematous, with no obvious deformities.
SKIN: No pallor. Good color. No visible rashes.
NEURO: No obvious neurological deficits, and he moves without evidence of cerebellar infarction.
MUSCULOSKELETAL: No obvious long bone fractures or dislocations.
EXAMS – URI:
GENERAL: He appears nourished & normally developed for his age.
EYES: Head exam is unremarkable. No scleral icterus or orbital trauma noted.
HEENT: Mucous membranes moist. His nasal turbinates are slightly indurated and erythematous consistent with a URI. Not too much rhinorrhea. Throat is minimally erythematous without obvious evidence of strep throat. Neck is supple without prominent lymphadenopathy.
LUNGS: Lungs are clear to auscultation. Some cough reported, but no respiratory distress at this time.
CARDIAC: Rhythm is regular. No dysrhythmias or murmurs.
ABDOMEN: Nontender with no obvious masses, and no peritoneal signs.
EXTREMITIES: Nonedematous, with no obvious deformities.
SKIN: Good color. No pallor. Warm/dry. No significant rashes.
NEURO: No obvious neurological deficits, and he moves without evidence of cerebellar infarction.
EXAMS – strep throat:
GENERAL: He appears nourished and normally developed for his age.
EYES: Head exam is unremarkable. No scleral icterus or orbital trauma noted.
HEENT: Mucous membranes moist. There is oral pharyngeal erythema, and some early exudates consistent with strep pharyngitis. The neck is supple but there is some tender anterior cervical lymphadenopathy. Clinically no evidence of meningitis. Nares patent without copious rhinorrhea.
LUNGS: Lungs are clear to auscultation, without any respiratory distress. No significant cough was appreciated.
CARDIAC: Rhythm is regular. No dysrhythmias or murmurs.
ABDOMEN: Nontender with no obvious masses, and no peritoneal signs.
EXTREMITIES: Nonedematous, with no obvious deformities.
SKIN: Good color, with no significant rashes. No pallor.
NEURO: No obvious neurological deficits, & he moves without evidence of cerebellar infarction.
EXAMS – back :
GENERAL: He appears to be in some pain, well-nourished & normally developed for his age.
EYES: Head exam is unremarkable. No scleral icterus or orbital trauma noted.
HEENT: Mucous membranes moist. Nares patent without copious rhinorrhea. No enlarged lymphadenopathy.
LUNGS: Lungs are clear to auscultation, without any respiratory distress.
CARDIAC: Rhythm is regular. No dysrhythmias or murmurs.
ABDOMEN: Nontender with no obvious masses, and no peritoneal signs.
EXTREMITIES: Nonedematous, with no obvious deformities.
SKIN: Good color, with no significant rashes. No pallor.
NEURO: No obvious neurological deficits. He moves without difficulty.
MUSCULOSKELETAL: He has some generalized lower back tenderness to palpation. No localized, midline bony tenderness, and no evidence of fracture. Lower extremity motor function is normal. Lower extremity sensation is intact. DTRs are equal and normal bilaterally. Pain is most likely due to soft-tissue pain (muscular and/or ligamentous).
EXAMS – neuro:
GENERAL: He appears alert & normally developed for his age.
EYES: Head exam is unremarkable. No scleral icterus or orbital trauma noted.
HEENT: Mucous membranes moist. Nares patent without copious rhinorrhea.
LUNGS: No cough and no respiratory distress.
CARDIAC: Rhythm is regular. No dysrhythmias or murmurs.
ABDOMEN: Nonsurgical with no peritoneal signs.
EXTREMITIES: Nonedematous, with no obvious deformities.
SKIN: No pallor. Good color. No visible rashes.
NEURO: His is cognitive, alert & oriented x 3. Conversive. Cranial nerves 2-12 are grossly intact. He appears to have normal 5 out of 5 strength. No obvious sensory deficits. DTRs are preserved and equal bilaterally. He moves without difficulty, and does not display any ataxia or cerebellar deficits.