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General Appearance
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Alert and cooperative, well nourished, no acute distress
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General Abormal
• • •
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General Comments
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Head
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normocepalic, atraumatic
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Head Abormal
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Head Comments
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Eyes
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PERRLA, EOMI, Fundi normal, vision is grossly intact.
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Eye Abnormal
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Eye Comments
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Ears
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auditory canals clear, tympanic membrane intact and clear
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Ear Abnormal
• • •
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Ear Comments
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Nose
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No nasal discharge, nares patent, no lesions
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Nose Abnormal
• • •
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Nose Comments
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Throat
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Oral cavity and pharynx normal, no lesions, no inflammation, teeth & gingiva in good general condition
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Throat Abnormal
• • •
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Throat Comments
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Neck
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Neck supple, non-tender without lymphadenopathy, masses or thyromegaly
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Neck Abnormal
• • •
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Neck Comments
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Skin
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no lesions, no rash, warm, dry, normal color
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Skin Abnormal
• • •
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Skin Comments
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Cardiovascular
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regular rate & rhythm, no murmurs, S1, S2 normal
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Cardiovascular Abnormal
• • •
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Cardiovascular Comments
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Lungs
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unlabored, clear to auscultation, no wheezing, no diminished breath sounds
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Lungs Abnormal
• • •
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Lungs Comments
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Abdomen
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soft, nontender, nondistended, bowel sounds present.
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Abdomen Abnormal
• • •
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Abdomen Comments
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Musculoskeletal
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normal muscle tone/bulk, no deformities, normal range of motion, normal spine alignment
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Musculoskeletal Abnormal
• • •
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Musculoskeletal Comments
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Back
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Normal gait & posture, no deformity, without tenderness, decreased range of motion, or muscular spasm.
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Back Abnormal
• • •
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Back Comments
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Extremities
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no varicose veins, no edema, no abnormal movements, no tremor, no rigidity, normal alignment, normal gait
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Extremities Abnormal
• • •
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Extremities Comments
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Neurological
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nonfocal, cranial nerves 2-12 intact, motor strength normal upper and lower extremities, no tremor, sensory exam intact.
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Neurological Abnormal
• • •
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Neurological Comments
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Psychiatric
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Alert, oriented, cognitive function intact, cooperative, judgement, and insight, mood/affect full range, non-suicidal
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Psychiatric Abnormal
• • •
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Psychiatric Comments
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Breasts
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no masses noted, tenderness, asymmetry, nipple discharge, or lymphadenopathy
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Breasts Abnormal
• • •
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Breasts Comments
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Male Genitalia
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Female Genitalia
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Pelvic
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Normally developed with no external lesions or eruptions. Vagina/cervix have no lesions, inflammation, discharge, tenderness.
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Pelvic Abnormal
• • •
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Pelvic Comments
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Genitalia
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Normally developed, no scrotal mass/tenderness, no hernias, no perineal abnormalities seen, no lesions or discharge.
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Gentalia Abnormal
• • •
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Genitalia Comments
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