| General | Ms. Jones, a pleasant, obese 28-year-old African American woman in no acute distress. Alert and oriented. |
| Head | Normocephalic, atraumatic. Scalp with no masses, normal hair distribution. |
| Eyes | Bilateral eyes with equal hair distribution, no lesions, ptosis, or edema. Conjunctiva clear and injected. Extraocular movements intact bilaterally. Pupils equal, round, and reactive to light bilaterally. Normal convergence. Left eye vision: 20/20, right eye vision: 20/40. Fundoscopic exam reveals mild retinopathic changes. |
| Ears | Equal ear shape. External canals without inflammation. Tympanic membranes pearly grey and intact bilaterally. |
| Nose | Septum midline, nasal mucosa boggy and pale bilaterally. No pain with sinus palpation. |
| Mouth/Throat | Moist buccal mucosa, no wounds. Adequate dental hygiene. Uvula midline. Tonsils 1+, posterior pharynx slightly erythematous with mild cobblestoning. |
| Neck | No lymphadenopathy. Thyroid smooth without nodules. Acanthosis nigricans present. Carotid pulses 2+, no thrills. Jaw with no clicks, full range of motion. Bilateral carotid artery auscultation without bruit. |
| Respiratory | Symmetrical chest, clear lung sounds, no wheezes, crackles, or cough. |
