Physical Exam Template
PHYSICAL EXAMINATION:
GENERAL: The patient is well developed and nontoxic.
VITAL SIGNS: Temperature 98.2, pulse 84, respirations 18, blood pressure 174/100, room air pulse ox 96%; that is within normal limits.
HEENT: Nonicteric sclerae, PERRLA, EOMI. Oropharynx clear. Moist mucous membranes. Conjunctivae appear well perfused.
CHEST: Chest wall is nontender.
HEART: Regular rate and rhythm without murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
GENITAL: Normal testicular lie. No signs of ecchymosis. There is some blood from meatus of this noncircumcised male. No crepitation. There is no obvious trauma to the phallus that is visible from the exterior. It is nontender.
RECTAL: Deferred.
SKIN: No rash, no excessive bruising, petechiae, or purpura.
NEUROLOGIC: Cranial nerves II-XII intact without motor/sensory deficit.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 138/84, pulse 106, respiratory rate 18, temperature 98.2, and pulse ox 99% on room air. GENERAL: The patient is awake, alert, and oriented, in no apparent distress. HEENT: Atraumatic, normocephalic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear. The oropharynx is clear with pink moist mucous membranes. NECK: Supple. There is no lymphadenopathy. MUSCULOSKELETAL: With full range of motion in all four extremities and all joints, muscle groups. No joint deformity or redness with the exception of the right index DIP joint. SKIN: Warm and dry, no evidence of rash. The patient has a 1.5 cm laceration present over the DIP crease on the palmar surface, volar surface, of his right index finger with some significant scar tissue formed. He has difficulty in flexing this joint. There is no redness or purulence noted or expressible. Sensation is intact distally. NEUROLOGIC: Intact. Moving upper extremities symmetrically and spontaneously and following commands.
PHYSICAL EXAMINATION:
VITAL SIGNS: Height is 5 feet 6 inches. Weight is 136 pounds. Blood pressure is 120/66, pulse is 68, respirations are 16, and temperature is 98.2 degrees.
GENERAL: This is a well-developed female in no acute distress.
HEENT: Pupils are equal, round, and reactive to light. Conjunctivae are pink. Tympanic membranes are within normal limits bilaterally.
HEART: Cardiac exam reveals a regular rhythm and rate without murmur or gallop. There is no carotid or abdominal bruits.
BREASTS: Breast exam reveals no masses, skin changes, or axillary adenopathy.
ABDOMEN: Reveals normoactive bowel sounds, soft, nontender, no organomegaly.
PELVIC: Exam reveals normal external female genitalia. She has a normal cervix, small uterus, no adnexal fullness.
EXTREMITIES: Lower extremities reveal no edema, 2+ pulses.
BACK: Low Back: The patient is tender to palpation over her left SI joint, more than on the right side. She has good range of motion of both hips. She has a negative straight leg raise. She has 5/5 strength of her legs. Her gait is normal.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/72, pulse 74, respirations 18, O2 sat 100% on room air, and temperature is 99.2.
GENERAL: Otherwise healthy, well-developed, well-nourished, (XX)-year-old female who is alert and oriented x3, nontoxic, in no apparent distress.
EXTREMITIES: On examination of the left lower extremity, the patient has a very small, approximately nickel-sized abscess to the anterior aspect of her left lower extremity with some small surrounding cellulitis. She has no lymphangitis, has no bleeding or drainage noted at this time. She has no posterior pain or swelling. She has no circumferential cellulitis. Full range of motion of her extremity. She is able to ambulate with normal sensation and good pulse.
PHYSICAL EXAMINATION:
GENERAL: The patient is well developed and nontoxic.
VITAL SIGNS: Temperature is 98.6, pulse 92, respirations 18, blood pressure 138/90, room air pulse ox 95% is within normal limits.
HEENT: Nonicteric sclerae, PERRLA, EOMI. Oropharynx clear. Moist mucous membranes.
CHEST: Chest wall nontender.
HEART: Regular rate and rhythm. No murmurs, clicks, gallops, rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly, no pulsatile mass, no Murphy’s sign. No Cullen’s or Grey Turner’s sign.
RECTAL: Deferred.
GENITAL: Deferred.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: Cranial nerves II-XII intact without motor, sensory, or cerebellar deficit, no asterixis.
SKIN: No rash.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 110/66, pulse 128, respiratory rate 18, temperature 99.6, O2 sat 95% on room air.
GENERAL: The patient is alert and oriented, in no apparent distress. She is pleasant and conversant in full sentences.
HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes are moist without lesions.
NECK: The patient has no noted JVD. No adenopathy is appreciated.
CHEST/LUNGS: The patient does have a port intact to her chest without any surrounding evidence of erythema or infection. Her lungs are clear bilaterally without rhonchi, rales, or wheezes. There is no subcutaneous air appreciated. There is no tenderness to the chest wall.
HEART: The patient has a regular rate and rhythm. No murmurs, rubs, or gallops are appreciated. Distal pulses are 2+. No carotid bruits appreciated.
ABDOMEN: The patient’s abdomen is completely soft, nontender, and nondistended. Bowel sounds are positive. No organomegaly is appreciated. No masses are appreciated. There are no peritoneal signs. There is no Murphy’s sign.
EXTREMITIES: The patient has no peripheral edema. There is no focal long bone tenderness or deformity.
SKIN: The patient’s skin is warm and dry, without rashes or lesions.
PSYCHIATRIC: The patient has normal mental status and has an appropriate affect.
NEUROLOGIC: The patient has 5/5 strength to the upper and lower extremities bilaterally. Sensation is intact throughout. Gait is within normal limits. Deep tendon reflexes are 2+ in all four extremities. There are no deficits to the cranial nerves.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 96/54, temperature 98.6, pulse 104, respirations 16, 99% on room air.
GENERAL: Awake, alert, comfortable appearing, in no acute distress.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. No nasal discharge. No facial trauma. Intraoral exam shows moist mucous membranes with no tonsillar enlargement or exudate. Tympanic membranes are normal. The canals are clear.
NECK: Supple with no cervical lymphadenopathy No meningismus. No goiter.
HEART: Regular rate without murmur, rub, or gallop.
LUNGS: Equal breath sounds bilaterally with no wheezing, rales, or rhonchi. There is no chest wall tenderness or instability.
ABDOMEN: No external sign of injury. Bowel sounds are present. Abdomen is soft, nontender. No rebound, no guarding, no rigidity. There are no palpable masses. There is no flank pain on exam.
EXTREMITIES: Strong peripheral pulses. There is no clubbing, no cyanosis, and no edema.
SKIN: No rash.
PELVIC: Pelvic examination was performed. Uterus was slightly enlarged. There was absolutely no blood whatsoever or discharge from the cervix. She has no adnexal masses or tenderness noted.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 172/88, temperature 98.4, pulse 112, respirations 26, SaO2 is 92% on room air.
GENERAL APPEARANCE: The patient is alert and oriented, in no acute distress.
HEENT: PERRLA. Extraocular movements are intact. Sclerae are anicteric. Conjunctivae are clear. ENT: Ears, nose, and throat are clear.
NECK: Supple without adenopathy. Thyroid is normal. Carotids free of bruit.
LUNGS: Coarse basilar rales are noted.
HEART: Regular rate and rhythm without murmur, rub or gallop. Slight jugular venous distention is present.
ABDOMEN: Soft and nontender. Active bowel sounds. No organomegaly.
SKIN: Clear, free of rash.
NEUROLOGIC: Cranial nerves II through XII intact. Distal, motor, and sensory exam is grossly intact.
MUSCULOSKELETAL: Full range of motion of all 4 extremities without pain. Calves are nontender with a negative Homans’. She does have profound kyphosis of the thoracic spine.
PHYSICAL EXAM:
VITAL SIGNS: Temperature is 97.8, BP is 116/86, pulse 72, respirations 18, O2 sat is 98% on room air.
GENERAL: The patient is a well-developed, well-nourished Hispanic male who is alert and oriented. He is in no acute distress.
HEENT: Head is normocephalic, atraumatic. The patient’s eyes are PERRLA, EOMI. Oropharynx is clear. Uvula is midline.
NECK: Supple, nontender. No lymphadenopathy present.
HEART: Regular rate and rhythm, equal S1, S2. No murmur, rub or gallop.
LUNGS: Clear bilaterally. No wheezes, rhonchi or rales.
ABDOMEN: Soft, nontender, and nondistended with active bowel sounds.
EXTREMITIES: There is no clubbing, no cyanosis. His radial, DP, and PT pulses are intact and symmetric. In the patient’s right lower extremity, he does have an incision site midline across his right knee. There are no staples or sutures in place. There is no wound dehiscence, no evidence of erythema, edema, no evidence of cellulitis or purulent drainage. He has no fluctuance with palpation. On the patient’s left lower extremity, essentially, distally from the mid shaft of his tibia distally down to the toes, it is erythematous and edematous. It is minimally tender with touch. There is no lymphangitic streaking. No palpable cords or masses appreciated with palpation of his calf, but he does have tenderness with palpation of his calf muscle. The edema is only midshaft up the tibia. He has good palpable femoral pulses and has full range of motion with plantarflexion, dorsiflexion against resistance, as well as flexion and extension of his left knee.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 114/66, pulse 86, respirations 22, temperature 100.6, pulse ox is 95%.
GENERAL: She is awake, alert, and oriented in mild distress secondary to pain from her buttocks.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales, or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs, or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
RECTAL: Does not reveal any mass inside the rectal vault. There is tenderness to palpation of the abscess area. The abscess does not seem to enter the rectal area or the genital area.
INTEGUMENTARY: The patient has a large 6.5 cm x 6 cm abscess on her left buttock with a surrounding area of cellulitis.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal.
