PA: OF 28-9009
lying;
blood pressure was
110/75,
pulse
90 and regular when sitting;
and
blood pressure went to 95/70 and pulse 100, when the patient stood up.
Respiratory
rate was
General:
She
16 and she was afebrile.
is
a well-developed,
well-nourished
female
in
no
acute
distress, has a very rounded facies.
Skin was warm and dry.
Skin on the
feet very coarse.
There were a few scars on the lower extremities
bilaterally.
She has supraclavicular fat pads but no buffalo hump.
Skin is
also darkened and coarse around the neck and in the axillae.
Head, Eyes, Ears, Nose and Throat:
Pupils were equal, round and reactive to
Normocephalic.
There were no nodes.
light.
Extraocular movements were
full.
There was no nystagmus. Discs were sharp.
Visual fields were within
normal limits to direct confrontation.
Tympanic membranes were clear.
Throat
was
clear,
uvula
midline.
Inferior
turbinates
were
normal.
Neck:
Supple. There were no nodes.
Trachea was midline.
There was no
palpable thyroid nodules or enlargement of the gland.
Carotids were 2+
bilaterally without bruits,.
Back:
No
CVA
tenderness.
Breasts:
Small, symmetrical.
Nipple was inverted on the right.
were no masses and I was not able to express any milk on examination.
were no axillary nodes.
She had normal axillary hair.
Both
Cardiac:
PMI was in the 5th intercostal space, midclavicular
St and S2 were normal.
There were no murmurs or gallops.
Lungs:
There
There
line.
Clear to auscultation and percussion.
Abdomen:
organomegaly
or
Soft,
and non-tender with good
masses.
Extremities:
There were
No clubbing,
no
tore.
There was no
bruits appreciated.
cyanosis or edema.
All pulses were 2+
bilaterally.
Neurologic:
Cranial nerves II through XII were intact.
Motor
examination was normal for both upper and lower extremities.
Cerebellar
function was thought to be intact.
There was no Romberg.
She had normal
sensation to vibration and light touch.
Deep tendon reflexes were 2+ in the
extremities,
Babinskis.
Genitalia:
1+
There
external
genitalia.
Admitted
on
at
the
knees,
is normal
trace
female
at
the
pubic
ankles
hair,
and
Tanner
there
Stage
8-23-82
qe
a)
31
_—
CD
normal
History and Physica! Examination (HPE)
Discharge Summary (DS)
DS Combined with HPE
~] Interim Summary (IS)
C3
V,
no
Operetion Report (OPN)
[_} IS Combined with HPE
Addendum Summary (AS)
co
were
‘
JURO0RO
upper
cr
-