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Physical Exam Note

Physical Exam Noataiton

QuestionAnswer
General WDWN Male in no apparent distress. Well groomed, appears stated age. Is pleasant and cooperative
Head (H) NCAT. Scalp without lesions
Eyes (E) Sclere white and conjuctiva clear with no discharge. PERRLA. Red reflex present bilaterally. Fundoscopic exam showsOptic disk visualized with sharp margins
Ear (E) Ear canals patent with no sewlling. Auditory acuity within normal. Tympanic membrane in tact with no erythema bilaterally.Cone of light visualized bilaterally
Nose (N) Symmetrical and nasal septum in tact. Nasal mucosa moist, turbinates appear normal with no bogginess. No frontal or maxillary sinus tenderness.
Throat (T) No lesions on lips, tongue, or oral mucosa. Good dentition with no cavitities seen. Oral mucosa moist. No tonsilar erythema, swelling or exudates.
Neck Supple. Trachea midline. No palpable masses. No lymphadenopathy. No thyromegally.
Cardiovascular RRR. Dorsalis pedis and radial pulses palpated bilaterally and equal
Respiratory Symmetrical chest wall expansion. CTA bilaterally. Equal breath sounds bilaterally. Percussion resonant.
Abdomen Appears soft, nondistended. Bowel sounds present in all 4 quadrants.Percussion is tympanic. No tenderness. No palpable masses
MS Upper and lower extremities appear symmetric. No TART changes noted. No joint deformities or swelling. Full ROM in all upper a lower extremity joints.
Neuro A&O x4 . DTR 2+/4 bilaterally patellar tendon and biceps tendon. Full and equal motor strength in bilateral upper and lower extremities. Gross sensation in tact in bilateral upper and lower extremities. Coordinated and stable gait and balance
skin Normal skin turgor with no skin tenting. No lesions or rashes seen. No suspicious moles seen.
Created by: precision09
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