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Exercise 5

A 65-year-old white male was admitted with suspected cancer of the larynx. At the time of admission, he was in good health except for a sore throat. With respect to the physical examination findings, his medical record contained the following information.

Term Word Elements Definition
Skin Clear  
HEENT See diagram Record contained a diagram of the head,eyes, ears, nose, and throat
Neck Without nodes No palpable lymph nodes
Chest Clear to P and A Percussion and auscultation revealed no abnormal conditions
Heart NSR without (M), thrill Normal sinus rhythm (NSR) without murmur (M) or vibratory sensation (thrill)
ABD Without palp. organs or masses By palpation, no enlarged organs, no masses in the abdomen

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