|
General Condition - Looks well
|
Hydration
|
|
Jaundice:
|
Pallor
|
|
Cyanosis
|
Clubbing
|
|
Edema
|
Lymphadenopathy
|
|
Conscious level
|
Other
|
|
|
|
|
OTHER SIGNS
|
|
|
Heart sounds: Normal no murmurs
|
Chest: Normal breath sounds
|
|
Abdomen: Soft non tender/no rebound or guarding
|
Skin: No rash
|
|
Vascular: Normal peripheral pulse
|
Neurological:Alert oriented in time,place/person
|
|
Musculoskeletal: No signs of arthritis
|
Other
|
|
|
|
|
General WNL
|
General Abnormal
• • •
|
|
General Comments
|
|
|
HEENT WNL
|
HEENT Abnormal
• • •
|
|
HEENT Comments
|
|
|
Skin WNL
|
Skin Lesion
|
|
Skin Comments
|
|
|
Neck WNL
|
Neck Abnormal
• • •
|
|
Neck Comments
|
|
|
Cardiovascular WNL
|
Cardiovascular Abnormal
• • •
|
|
Cardiovascular Comments
|
|
|
Lungs WNL
|
Lungs Abnormal
• • •
|
|
Lungs Comments
|
|
|
Abdomen WNL
|
Abdomen Abnormal
• • •
|
|
Abdomen Comments
|
|
|
MSK WNL
|
MSK Abnormal
• • •
|
|
MSK Comments
|
|
|
Breasts WNL
|
Breasts Abnormal
• • •
|
|
Breasts Comments
|
|
|
Neuro WNL
|
Neuro Abnormal
• • •
|
|
Neuro Comments
|
|
|
Extremities WNL
|
Extrem Abnormal
• • •
|
|
Extrem Comments
|
|
