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Physical Exam Write Up Ideal

The physical exam showed an alert, well-appearing man with normal vital signs. His head, eyes, ears, nose, throat, neck, heart, lungs, abdomen, extremities, muscles, nerves and mental status were all found to be normal, with no abnormalities noted.

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6K views2 pages

Physical Exam Write Up Ideal

The physical exam showed an alert, well-appearing man with normal vital signs. His head, eyes, ears, nose, throat, neck, heart, lungs, abdomen, extremities, muscles, nerves and mental status were all found to be normal, with no abnormalities noted.

Uploaded by

sintwala
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Physical Exam

General: well-appearing man laying in a supine position in NAD

HEENT: Skull is normocephalic/atraumatic. Hair is average texture.

Eyes: Sclera white, conjunctiva pink. Pupils are 4mm constricting to


2mm, equally round and reactive to light and accomodations. Disc
margins sharp; no hemorrhages or exudates, no arteriolar narrowing.

Nose: Nasal mucosa pink, septum midline, no sinus tenderness

Throat: Oral mucosa pink, dentition good, pharynx without exudates

Neck: Trachea midline. Neck supple; thyroid isthmus palpable, lobes


not felt.

Lymph Nodes: No cervical, axillary, epitrochlear, inguinal adenopathy.

Cardiovascular Exam: The JVP is 3 cm above the sternal angle with


head of the bed elevated to 30 degrees. Carotid upstrokes are brisk,
without bruis. The PMI is tapping, 7 cm lateral to the midsternal line in
the 5th intercostal space. S1, S2, no murmurs, rubs, clicks or gallops.
No carotid or renal bruis. Capillary refill less than 2 seconds. Pulses 2+
bilaterally

Pulmonary Exam: Thorax is symmetric with good expansion. Lungs


resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi.
Diaphragms descend 4cm bilaterally.

Abdominal Exam: Abdomen is protuberant with active bowel sounds


in all four quandrants. It is soft and nontender; no masses or
hepatosplenomegaly. Liver Span is 7cm in the right midclavicular line;
edge is smooth and palpable 1 cm below the right costal margin.
Spleen and kidneys not felt. No costovertebral angle tenderness.

Extremities: Extremities are warm and without edema. No


varicosities or stasis changes. Calves are supple and nontender. No
femoral or abdominal bruits. Brachial, Radial, femoral, popliteal,
dorsalis pedis, and posterior tibial pulses are 2+ and symmetric.

Musculoskeletal: Good Range of motion in all joints. No evidence of


swelling or deformity.

Neurological Exam: Alert, relaxed, and cooperative. Oriented to


person, place, and time. Cranial Nerves II-XII intact.

Motor: Good muscle bulk and tone. Strength 5/5 throughout.


Cerebellar- rapid alternating movements, finger to nose, and heel to
shin intact.

Romberg- maintains balance with eyes closed. No pronator drift

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