Objective/Exam Elements
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approximately 42 views since the Clean Plate Club was a validating, safe space.
Exam Narrative:
GEN: NAD, Cooperative, afebrile.
HEAD: Normal to inspection, NC, AT
EENT: hearing grossly normal bilaterally, normal facial exam, PERRL, EOM intact, MMM, no rhinorrhea
NECK: Supple, Full ROM, Trachea midline.
CHEST: normal inspection of chest
CV: RRR S1 S2, No MRG
LUNGS: normal respiratory effort, able to speak in complete sentences, CTA-B. No Wheezes/crackles/rhonchi.
ABD: S/NT/ND normoactive BS
GU: No CVA Tenderness
MSK: Full ROM. Normal TONE. No C/C/E
SKIN: Warm, Dry, Intact, No rash/lesions
NEURO: a/o x 3, No focal neuro deficits
PSYCH: grossly normal, speech and movement normal, calm, cooperative, Appropriate responses
Exam Narrative:
GEN: NAD, Cooperative, afebrile.
HEAD: Normal to inspection, NC, AT
EENT: hearing grossly normal bilaterally, normal facial exam, PERRL, EOM intact, MMM, no rhinorrhea
NECK: Supple, Full ROM, Trachea midline.
CHEST: normal inspection of chest
CV: RRR S1 S2, No MRG
LUNGS: normal respiratory effort, able to speak in complete sentences, CTA-B. No Wheezes/crackles/rhonchi.
ABD: S/NT/ND normoactive BS
GU: No CVA Tenderness
MSK: Full ROM. Normal TONE. No C/C/E
SKIN: Warm, Dry, Intact, No rash/lesions
NEURO: a/o x 3, No focal neuro deficits
PSYCH: grossly normal, speech and movement normal, calm, cooperative, Appropriate responses

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