General Adult Exam

GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
HEENT: Normocephalic. PERRL, EOMI. Fundi normal, vision is grossly intact. External auditory canals and tympanic membranes clear, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
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.
GI: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
MSK: Adequately aligned spine with no deformities. Normal gait and posture. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Peripheral pulses intact. No varicosities.[LOWER EXTREMITY] Feet are 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; ankles, knees, legs, and hips reveal 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: Oriented to person, place, and time. Normal affect, mood, and behavior.
GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
HEENT: Normocephalic. PERRL, EOMI. Fundi normal, vision is grossly intact. External auditory canals and tympanic membranes clear, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition. Neck supple, non-tender without lymphadenopathy, masses or thyromegaly.
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.
GI: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses.
MSK: Adequately aligned spine with no deformities. Normal gait and posture. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Peripheral pulses intact. No varicosities.[LOWER EXTREMITY] Feet are 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; ankles, knees, legs, and hips reveal 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: Oriented to person, place, and time. Normal affect, mood, and behavior.

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