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Acute Adult Physical Exams

by Mark Morgan on November 26, 2010

in General

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Allergic rhinitis
General Appearance: alert, NAD. Nose: normal, mucosa without edema or inflammation. No clear or purulent nasal discharge. Ears: TMs bilaterally intact, without bulging or erythema. Eyes: normal conjunctiva, lids, PERRL Throat: normal, without erythema, tonsillar inflammation or exudate. No posterior pharyngeal drainage Lungs: clear to ausculation bilaterally. No wheezes or crackles. Heart: RR; no murmur/click, S3/S4
Pharyngitis
GEN: Alert, well nourished and well hydrated, in no distress. HEENT: Conjunctiva normal. Auditory canals normal. Right tympanic membrane is intact without fluid or erythema. Left tympanic membrane: is intact without fluid or erythema. Nares without clear or mucopurulent rhinorrhea bilaterally. Oral exam without lesions, posterior pharynx without erythema or tonsillar exudates; no palatal petechiae. NECK: Supple, tender adenopathy anteriorly; no posterior nodes palpable. LUNGS: Clear to auscultation without wheezes, rales, or rhonchi. Good excursions. No dullness on percussion. COR: RRR with normal S1, S2 without murmur, gallop, or rub. ABD: Soft, non-tender, without hepatosplenomegaly SKIN: No rash present
Conjunctivitis
General Appearance: NAD Visual acuity: Normal, Snellen results as recorded by nurse Left eye exam: normal, PERRL, extraocular movements normal. Conjunctiva without injection. Mattering and excessive tearing is absent. No visible corneal abrasion or foreign body. Eyelids normal. Fundus normal. Right eye exam: normal, PERRL, extraocular movements normal. Conjunctiva without injection. Mattering and excessive tearing is absent. No visible corneal abrasion or foreign body. Eyelids normal. Fundus normal. Fluorescein exam of affected eye is normal, without corneal abrasion.
Stye
General Appearance: NAD Eyes: visual acuity as recorded by nurse, pupils equal and reactive, EOMI, funduscopic exam normal, corneas normal, conjunctiva normal without injection. Eyelids: left without erythema or swelling. no visible pustule or mass. No drainage. right without erythema or swelling. no visible pustule or mass. No drainage. There is no periorbital swelling. Ears: normal TMs bilaterally. Lymph nodes: normal. no anterior or posterior cervial adenopathy.
Otitis
General: Patient is alert and in no distress. Head: Normocephalic. ENT: External examination of the nose is normal. External examination of the ears is normal. Internal examination of the nose without congestion. Right tympanic membrane is intact without fluid or erythema. Left tympanic membrane is intact without fluid or erythema. Throat: Without tonsillar hypertrophy or exudate. No erythema at posterior pharynx. Neck: Supple, negative Kernig and Brudzinski Heart: RR, no murmur/click. Lungs: Clear to auscultation and percussion, without rhonchi or wheezes.
Dizziness
General Appearance: No distress. EENT: PERRL, fundi normal, ears normal. Positional testing for nystagmus do not elicit subjective symptoms or vertigo or nystagmus. Heart: RR, no murmur/click, S3/S4 Lungs: clear to auscultation bilaterally. Neuro: symmetric DTR's, strength intact/symmetric, Babinski sign is absent, finger to nose is normal, tandem walking is normal. Cranial nerves 2-12 are normal.
Migraine/Headache
General Appearance: alert, NAD. Photophobia is not apparent. Eyes: PERRL, fundi normal, EOMI HENT: ears normal, pharynx normal. Neck: supple Heart: RR, normal S1 and S2, no murmur Lungs: clear to auscultation bilaterally. Neuro: Cranial nerves: 2-12 intact. Reflexes: normal, symmetric at upper and lower extremities. Babinski sign absent. Strength: normal, symmetric at upper and lower extremities. Cerebellar function tests: Romberg normal, finger to nose normal, tandem walking normal.
Bronchitis
General: Patient is alert and in no acute distress. ENT: No tonsillar hypertrophy or exudate. No erythema at posterior pharynx. External examination of the ears and nose is normal. Right tympanic membrane is intact without fluid or erythema. Left tympanic membrane: is intact without fluid or erythema. Lymph Nodes: no anterior cervical adenopathy. no posterior cervical adenopathy. Heart: RR; no murmur/click, S3/S4 Lungs: clear to auscultation and percussion bilaterally, no rhonchi or wheezes. Chest x-ray: negative for focal infiltrate, no bronchial inflammation, no bilateral perihilar infiltrates
Shortness of breath
General Appearance: No acute distress. Is not short of breath. Patient has no apparent cyanosis. Nose: without nasal discharge. Ears: normal bilaterally, bilateral TMs intact without bulging or erythema Throat: without tonsillar swelling or exudate. Lymph nodes: without anterior cervical, posterior cervical, or supraclavicular adenopathy. Heart: normal heart sounds no murmur, no JVD Lungs: normal, good air movement bilaterally, no wheezing, rhonchi, or rales. Lower extremities: normal, without pitting edema. Pulse oximetry: normal Chest x-ray: normal, without infiltrates.
Gastroenteritis
General Appearance: NAD. Skin: adequate turgor Ears: normal. Mouth: mucosa moist. pharynx is without erythema or tonsillar hypertrophy. Heart: normal heart sounds, no murmur Lung: clear without rhonchi or wheezes Abdomen: no mass, no tenderness nor organomegaly. bowel sounds are present
Urinary Tract Infection
General Appearance: well hydrated, alert, in no acute distress. BACK: no CVAT ABDOMEN: Soft, tender over the suprapubic area without masses or hepatosplenomegaly. Not distended. MALE: Genitalia: without urethral discharge Prostate: normal, not enlarged, nontender. Urethral culture/study was taken for GC/Chlam FEMALE: Pelvis: normal, without perineal erythema, vaginal discharge, or adnexal abnormality. no cervical motion tenderness. Dip UA shows no nitrite, leukocytes, or protein.