Discussion Part Two (graded) Physical Examination

Vital Signs:

• Height: 109 cm
• Weight: 27 kg
• Blood Pressure: 102/60 mmHg
• Temperature: 98.2°F
• Heart Rate: 88 bpm, regular
• Respiratory Rate: 18 breaths per minute, regular, non-labored
• SpO2: 99%

General:

• The patient is cooperative, talkative, and demonstrates appropriate behavior for her age.

HEENT (Head, Eyes, Ears, Nose, Throat):

• Head: Normocephalic, atraumatic. Hair is thick and evenly distributed throughout the scalp.
• Eyes: Conjunctivae are clear, non-icteric. Pupils are equal, round, reactive to light and accommodation (PERRLA). Extraocular movements (EOMs) are intact. Fundoscopic exam is unremarkable.
  • Vision (Snellen Exam): 20/50 in the left eye, 20/40 in the right eye, and 20/30 with both eyes together.
• Ears: Tympanic membranes are intact and unremarkable. The pinna and tragus are non-tender bilaterally.
• Nose: Nares are patent and unremarkable bilaterally.
• Throat: Pharynx is unremarkable with tonsils graded 1/4 bilaterally. Oral exam shows primary tooth eruption including first molars, upper and lower. No loose teeth. The oral cavity is otherwise unremarkable.
• Neck: Neck is supple without lymphadenopathy. Thyroid is small, firm, and equal bilaterally.

Cardiopulmonary:

• Heart: Regular rate and rhythm (RRR) without murmur.
• Lungs: Clear to auscultation (CTA) throughout. Respirations are even and unlabored.

Abdomen:

• Slightly rounded, with normoactive bowel sounds throughout. The abdomen is soft and non-tender, with no masses or organomegaly detected.

Peripheral Pulses:

• Peripheral pulses are regular, equal, and intact bilaterally in both radial and pedal arteries.

Genitourinary (GU):

• Labia majora and minora are intact, with no erythema or discharge noted.

Musculoskeletal:

• The patient moves all extremities (MAE) and is able to perform deep knee bends, hop on one foot with either leg, and balance on each leg for 10 seconds.

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Summary:The physical examination of the patient, Jo, reveals that she is generally healthy and well-developed for her age, with normal findings in her HEENT, cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal systems. The primary concern noted is a mild visual impairment as indicated by the Snellen exam, which may require further evaluation and possible referral to an optometrist. The rest of the examination findings are within normal limits, and there are no acute concerns noted.