Patient Note_Basic Format 2 ( Physical Examination)
VS (Vital Signs): Copy & Paste! or bp 90/60, p 80, T 36C, rr 17
GA (General Appearance): NAD (No Acute Distress)
HEENT & Neck
Head: NCAT, NT: NormoCephalic/ATraumatic, Non-Tender
Eyes: no scleral icterus/ anemic/ erythema/ exudate. PERRLA, EOMI,
Fundi- red reflex intact, no papilledema / No visual defect.
Ears: no discharge. NT. EAC NL, TM intact or TM: No bulging, perforation, redness b/l
Rinne AC>BC, Weber not lateralized
Nose: no nasal congestion, discharge, erythema, and perforation or salute
Throat: MMM (Mucous Membranes Moist). no exudate, tonsillar enlargement, erythema, exudates, vesicular lesions /
Neck: no LAD(Lymphadenopathy) / no Bruits, JVD/ thyroid No enlargement, nodules, tender and bruits
Full CV: RRR (Regular Rate and Rhythm), S1S2NL, no MRGs (Murmurs, Rubs, or Gallops), PMI (Point of Maximal Intensity) not displaced. Carotid: no bruits, no JVD, Pulses: Radial, DP, PT (Dorsalis pedis, post. Tibialis) 2+ b/l. No Edema in LE , Fundoscopy: no vessel changes & Exudate & Hemorrhage, no papilledema.
Chest: NT, equal chest excursion b/l, TVF NL (Tactile Vocal Fremitus Normal), Lungs clear to A&P(Auscultation, percussion) b/l, no WRR(Wheezing, Rales, Rhonchi).
Abdomen: no scars or bruises. Soft, ND (NonDistended) / BS (Bowel Sound) + x 4Q, no bruits. / tympanicx4Q. no masses & HSM(Hepatosplenomegaly)/ NT (NonTender)
Negative- Murphy, Rovsing ’s, psoas, obturator sign. CVA tenderness.
Full Neuro:
A&O3 (Alert to Oriented x3)
Eyes: no visual defect, EOMI, Fundoscopy- no vessel changes, hemorrhage,
CN2-12 grossly intact. motor 5/5 in all 4 ext, DTR: 2+ in all 4 ext., Sensory Intact to light touch SILT/position/vibration intact b/l.
No dysdiadochokinesia (flip hands), no dysmetria or [coordination intact], Roberg negative, Gait - NL,
Brudzinski +/ Babinski - / Kernig -
Extremities: IPR MSRP (Inspection, Palpitation, Range of movement, Motor, Sense, Reflex, Pulse)
No swelling, erythema, warmth, tenderness (Inspection, Palpitation)
ROM intact
Motor 5/5, Sensation intact to light touch, sharp and dull, DTR 2+ in all 4 extremities.
Peripheral pulses: 2+ DP, TP, Radialis b/l.
