Wednesday, November 25, 2009

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Physical Examination (common words)

Physical Examination (Common Terms)
GENERAL:
This is a well-developed, well-nourished adult in no distress.
VITAL SIGNS:
Weight: _____ blood pressure: _____, pulse: _____, respiratory rate _____.
Oxygen saturation is _____ on room air, which is normal for an adult.
BMI: _____ Ideal body weight _____.
HEENT (Head, eyes, ears, nose and throat)
HEAD: Atraumatic/normocephalic.
EYES
Extraocular motion is intact.
Extraocular movements are intact.
Pupils are equally round and reactive to light and accommodation.
Sclerae and conjunctivae are clear.
Pupils are equal, round, reactive to light and accommodation.
Funduscopic exam shows normal disks, normal vessels, no AV nicking and no hemorrhages.
Mucous membranes are moist.
Oropharynx is clear.
There is no nasal congestion noted.
EARS: Canals are patent without obstruction. There is no erythema or exudates in the canals. Tympanic membranes have normal light reflexes bilaterally.
NOSE: Nasal septum is intact with no polyps or perforation of the septum.
THROAT: The mucous membranes show no erythema in the posterior pharynx and no exudates. The uvula and tongue protrude to the midline. The buccal mucosa and gingiva are normal.
NECK:
Supple.
Trachea is midline.
Carotids are 2+ and equal and no bruits were heard over the carotid arteries.
The thyroid gland was normally palpable.
No adenopathy was present in the anterior or posterior deep cervical chain
No masses present.
Supple without adenopathy
Full range of motion.
CHEST/LUNGS/RESPIRATORY:
Clear to percussion and auscultation.
No rales, wheezes or rhonchi.
HEART/CARDIOVASCULAR:
Rhythm is regular without a murmur or gallop rhythm.
Heart sounds are normal.
Regular rate.
No murmur, rub, or gallop.
Distal circulation intact without cyanosis or clubbing noted.
ABDOMEN/GI/GASTROINTESTINAL:
Soft, nontender, no guarding or rebound tenderness.
Normal bowel sounds, without masses.
There are no bruits over the renal or femoral arteries.
The pulses in the groin, behind the knees and feet were equal and symmetric.
The abdomen is soft, nontender, nondistended.
There is no rebound and no masses are appreciated.
MUSCULOSKELETAL:
There is full range of motion of upper and lower extremities, without tenderness in any joint or muscle group.
No edema present.
No crepitation or clubbing is present.
No bone or joint abnormalities are noted. The patient is moving all 4 extremities well.
GU/GENITOURINARY:
Normal penile shaft without lesions.
Testicles are normal with no masses or hernia.
Rectal exam shows normal sphincter tone and no masses.
The stool is negative for occult blood.
NEUROLOGICAL:
Cranial nerves II-XII are grossly intact.
Deep tendon reflexes equal symmetrically.
There were no signs of unilateral or bilateral weakness or tremors.
The patient is alert and oriented x3.
Cranial nerves II through XII are grossly intact.
The patient is neurologically nonfocal.
INTEGUMENTARY/SKIN:
Skin is pink, warm, and dry.
No cyanosis.
No rashes or lesions.

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