General Adult Physical Exams

by Mark Morgan on November 26, 2010

in General

Tagged as: note-template

Select
General Adult
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. HEAD: normocephalic EYES: PERRL, EOMI. Fundi normal, vision is grossly intact EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Skin normal color, texture and turgor with no lesions or eruptions. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal.
General Male
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. HEAD: normocephalic EYES: PERRL, EOMI. Fundi normal, vision is grossly intact EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Skin normal color, texture and turgor with no lesions or eruptions. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal. GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge. RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular.
General Female
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. HEAD: normocephalic EYES: PERRL, EOMI. Fundi normal, vision is grossly intact EARS: External auditory canals and tympanic membranes clear, hearing grossly intact. NOSE: No nasal discharge. THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits. LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait. NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal. SKIN: Skin normal color, texture and turgor with no lesions or eruptions. PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal. PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness. BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy.