Sample Documentation of Physical Exam Findings

Sample Documentation of Physical Exam Findings

In a Complete and Comprehensive Health Assessment!

Mrs. N. is a short, moderately obese, 42 year old woman who walks and moves easily and responds quickly and appropriately to questions. Affect is pleasant with no evidence of anxiety or distress.

Pulse: 88

Resp: 12

Temp: 98.2 F

BP: 132/88

Height: 5’4”

Weight: 158 lbs

Skin: pink, warm, good turgor, no excoriations or lesions. Hair, normal texture, amount and distribution. Nailbeds pink, no deformities or clubbing.

Head:, scalp and skull normal, facial appearance appropriate and symmetrical.

Eyes: Vision 20/20 in each eye. Fields full by confrontation, EOM’s intact, no nystagmus. Conjunctiva pink, sclera clear. PERRLA. Disc margins sharp, cup normal. No nics, hemorrhages or exudates. Macula symmetrical bilaterally.

Ears: No masses, lesions or tenderness of auricles or canals. Wax partially obscures right drum. Left canal clear. Both TM intact and pearly grey, light reflex present and equal bilaterally.Acuity good (to whispered voice).

Nose: No obstruction, redness, discharge or deviation of septa. No maxillary or frontal sinus tenderness.

Mouth and throat: Mucosa and gingivae pink. No lesions or masses. Teeth in good repair. Tongue midline, no tremor. Tonsils absent. Pharynx pink, without lesions or exudates. Can clench teeth. Moves jaw freely.Gag reflex present. Uvula retracts centrally with phonation.

Neck: Full ROM without tenderness. Trachea midline. Thyroid not palpable. No lymphadenopathy.

Thorax and lungs: Thorax symmetrical. Good expansion. Lung fields resonant. Fremitus equal bilaterally. Vesicular breath sounds throughout. No adventitious sounds.

Breast: Symmetrical. Contour and consistency appropriate for age and parity. No masses or tenderness. Nipples erect without discharge. No axillary adenopathy.

Cardiac: Apical impulse at 5th intercostals space. No heaves, lifts or thrills. S1, S2 normal. No S3 or S4 . No murmurs, gallops, rubs or bruits.

Peripheral Vascular: All pulses strong and regular, no bruits. Normal JVP. Extremities warm, without pallor, cyanosis, edema. No varicosities or calf tenderness.

Abdomen: Symetrical, no masses, lesions, abnormal pulsations. Bowel sounds present, no bruits. No rigidity. No hepato-splenomegaly. No tenderness. No hernias. Normal abdominal tympany.

Musculo-skeletal: Full ROM, no tenderness. Normal gait, Romberg negative. Muscle strength intact.

Neurological: Alert and responsive. Thought process, memory and orientation intact. Appropriate behavior and speech. Reflexes 2+.