General: Appears healthy as stated age, in no acute distress.

Skin:
Clean and dry normal in appearance, texture, and temperature

Head: Normal appearance. Maxillary/frontal/ethmoid sinuses non-tender.

Normal Scalp and Hair.

Eyes:
EOMI, Visual Acuity 20/?? with Snellen Chart with or without corrective
lenses, 14/14 with Ishiharat Color test.
Pupils equally round, 4 mm, reactive to light and accommodation, sclera
and conjunctiva normal.
Fundoscopic examination reveals normal vessels without hemorrhage.

EARS
Tympanic membranes and external auditory canals normal.

Nose: Mucosa moist with no erythema. No septal deviation/perforation. No

polyps appreciated

Mouth: Lips, tongue and buccal mucosa unremarkable. Normal hard/soft

palate Oral pharynx is normal without erythema or exudate.

Normal dentition without visible caries. No gingival hypertrophy or obvious

periodontal inflammation

Throat: No erythema or exudates. No visible post-nasal drip or

cobblestoning. Normal tonsils. No masses seen

Neck: Supple with full ROM

Easily moveable without resistance, no abnormal adenopathy in the
cervical or supraclavicular areas. Trachea is midline and thyroid gland is
normal without masses.

Chest:
S1/S2 RRR without murmurs or abnormal heart sounds. Capillary refill time
is 2 sec. Symmetric chest excursions. Lungs are clear to auscultation and
percussion bilaterally PMI is in the 5th inter-costal space at the mid
clavicular line.

Breasts with no skin dimpling or retractions. No palpable breast masses or

nodules. No discharge or tenderness.

Abdomen:
The abdomen is symmetrical without distention; No visible venous
collaterals, bowel sounds are normal in quality and intensity in all areas; On
palpation, no tenderness, masses, guarding, rebound, ascites.

Extremities:
Full ROM, No cyanosis, clubbing, or edema are noted. Peripheral pulses
equal in the femoral, popliteal, anterior tibial, dorsalis pedis, brachial, and
radial areas are 2/2.

Back:
Spine is straight without vertebral anomalies. No vertebral or costo-
vertebral angle tenderness. Full ROM

Joints:
wrist, elbow, shoulder, hip, knee, ankles full range of motion without pain.
Hands-feet: full ROM, no cerpitus, pain on palpation or deformities.

Nodes:
No palpable nodes in the cervical, supraclavicular areas.

Genital/Rectal:
Normal rectal sphincter tone; no rectal masses or tenderness. Stool is
brown and guaiac negative. Pelvic why they were omitted exmaination
reveals normal external genitalia, and normal vagina and cervix on
speculum examination. Bimanual examination reveals no palpable uterus,
ovaries, or masses.

Neurological:
Cranial nerves II-XII are normal. Motor and sensory examination of the
upper and lower extremities is normal Motorstrenght 5/5. Gait and
cerebellar function are also normal. Reflexes 2+ normal and symmetrical
bilaterally in both extremities.

Assessment Plan:

Client physically able to perform job duties as outlined.

Client for pre-employment physical, See H&P, Snellen Vision chart,

Ishihara Test for Color Blindness and 5ft whisper test. Tuburcuin testing
with .10 ml PPD administered to LFA, Fit test for N95 Respirator mask,
Urine drug screen for illicit substances, and blood drawn and sent for
immunological titers (Varicella, MMR, Hep B), Client educated on safe
body mechanics’ for bending, moving, lifting and carrying within defined
job requirements.