Normal Physical Exam Documentation Flashcards

Normal Physical Exam Documentation

1
Q

General appearance

A

The patient is a well-developed well-nourished male/female resting comfortably in no acute distress.

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2
Q

Skin

A

Warm and dry. Good turgor. No rash, petechiae, or suspicious lesions. No jaundice.

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3
Q

Head

A

Normocephalic, atraumatic. Scalp without lesion. Hair with average texture and normal distribution.

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4
Q

Eyes

A

Visual acuity 20/20 bilaterally. Conjunctiva pink; sclera white. Pupils equal round, reactive to light and accommodation. Extraocular movements intact. Visual fields full by confrontation. Disc margins sharp without hemorrhages or exudates. No arteriolar narrowing or A-V nicking.

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5
Q

Ears

A

Tragus and auricle nontender. Acuity intact to finger rub bilaterally. External auditory canals clear. Tympanic membranes translucent with a good cone of light.

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6
Q

Nose

A

Mucosa pink. Septum midline.

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7
Q

Mouth

A

Moist mucous membranes without lesions. Good dentition. Oropharynx without erythema, tonsillar enlargement, or exudates. Soft palate rises symmetrically. The tongue is midline.

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8
Q

Neck

A

Supple with full range of motion. The trachea is midline. Thyroid without enlargement, nodule, or tenderness.

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9
Q

Lymph Nodes

A

No occipital, posterior auricular, pre-auricular, submandibular, submental, cervical or supraclavicular adenopathy.

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10
Q

Thorax and Lungs

A

Chest wall expansion is symmetrical. Resonant to percussion. Breath sounds vesicular with no added sounds. (Could also write “lungs clear without crackles, wheezes, or rhonchi.)

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11
Q

Cardiovascular

A

PMI in the 5th intercostal space, midclavicular line. Regular rhythm, normal S1 and S2, with physiologic splitting of S2. No murmurs, gallops or rubs. Carotid upstrokes brisk and without bruits bilaterally. Jugular venous pressure 3 cm above sternal angle.

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12
Q

Abdomen

A

Flat, soft, and non-tender with normoactive bowel sounds. No scars or striae. No aortic or renal bruits. No masses. Liver span 7cm in midclavicular line; edge smooth and palpable 1 cm below the right costal margin. No splenomegaly. Aorta width 2 cm.

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13
Q

Extremities

A

No clubbing, cyanosis or edema. Posterior tibial and dorsalis pedis pulses 2+ bilaterally.

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14
Q

Musculoskeletal

A

No obvious joint deformities. Joints without warmth, swelling, or tenderness. Good range of motion in neck, shoulders, elbows, wrists, hands, hips, knees, ankles, and back.

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15
Q

Neuro

A

Mental status: Alert and oriented.

Cranial Nerves:

II: visual acuity 20/20 bilaterally. Visual fields full by confrontation. Pupils are equal, round, and reactive to light and accommodation. Disc margins are sharp.

III, IV and VI: extraocular movements intact.

V: temporal and masseter strength intact, sensation intact to light touch

VII: able to raise eyebrows, squeeze eyelids shut against resistance, puff out cheeks, smile, frown

VIII: hearing intact to finger rub bilaterally

IX, X: palate rises symmetrically, uvula midline

XI: strength of sternocleidomastoid and trapezius 5/5 bilaterally

XII: tongue midline

Reflexes: biceps, triceps, brachioradialis, patellar, ankle reflexes 2+ bilaterally, toes down going on Babinski.

Sensory: light touch, pinprick, vibration and proprioception intact.

Motor: Good bulk and tone. Strength 5/5 throughout.
Coordination: Rapid alternating movements, finger tapping, finger to nose, and heel to shin intact.

Gait: Steady and without ataxia. Able to tandem walk, walk on heels, and walk on toes.

Romberg: Maintains balance with eyes closed

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16
Q

Breasts

A

Symmetric and without erythema, tenderness, skin changes, or masses. Nipples without discharge

17
Q

Genital (female)

A

External genitalia without erythema or lesions. Vaginal mucosa pink and well rugated and vaginal vault without discharge. Parous cervix without tenderness or discharge. Uterus anterior, midline, and without enlargement. No adnexal tenderness or masses. (Pap smear obtained.)
(Assistant: Jane Smith R.N.)

18
Q

Genital (male)

A

Circumcised male. No penile discharge or lesions. No scrotal swelling. Testes descended bilaterally, smooth, and without masses. Epididymis non-tender. No inguinal or femoral hernias.

19
Q

Rectal (male)

A

No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth, non-tender, and without enlargement or nodules. Median sulcus palpable. Stool brown, negative for occult blood.