Physical exam documentation

Physical exam

GENERAL APPEARANCE NAD, activity normal for age, well developed/ well nourished, no cyanosis, pallor, or diaphoresis.

EYES lids/conjunctiva normal.

EARS/NOSE/THROAT Mucous membranes moist, nares normal, lips/teeth normal uvula midline without oral pharyngeal erythema, exudate or swelling TMs normal bilaterally. No lymphangitis/lymphedema.

HEAD/NECK normocephalic atraumatic, no facial trauma, neck is supple.

RESPIRATORY respiratory effort normal, speaks in full sentences, no tripod position, no accessory muscle use. Lungs clear to auscultation without rhonchi, wheezes, rales

CARDIAC Regular rate and rhythm, no edema.

ABDOMINAL Soft, ND/NT. No evidence of fluid wave. No pulsatile masses on exam, rebound tenderness, Murphy sign or pain over Mcburney's point.

MUSCLES/EXTREMITIES No abnormal range of motion, no swelling.

SKIN Warm, pink and dry. No rashes, dermatoses, petechiae or lesions.

NEUROLOGICAL Speech is clear and appropriate. Normal level of consciousness. Gait and coordination are normal. 5/5 strength in all extremities.

PSYCH Normal mood and affect. Judgement/competence is appropriate

[This template meets CMS level 5 standards]

Cellulitis

Compartments soft. <2sec CRT. +2 pulse. Normal sensation. Nerves and tendons intact. No tenderness to palpation proximal or distal. No skip lesions. No fluctuance or signs of drainable abscess. No palpable crepitus.

Slit lamp exam

Slit Lamp with fluorescein

Lids/lashes = nl

Conjunctiva = cl

Cornea = cl

Anterior chamber = D/Q

Iris = R/R

Lens = cl

No FB noted on extensive exam

Knee

Anterior/posterior/varus/valgus/McMurry's tests negative. Patella in place. No instability of knee. Negative Ballottement test. Neg axial load.

Ortho normal

No open fracture. Compartments soft. <2sec CRT. +2 pulse. Normal sensation. Nerves and tendons intact. No tenderness to palpation proximal or distal. No retained foreign body or signs of infection.

Ortho upper extremity

bilateral upper extremities fires ain/pin/u slit fwds/sf/if, radial 2+, CRT <2s

Ortho lower extremity

bilateral lower extermities

Sensory: SILT S/S/DP/SP/T

FIRES TA, EHL, GS, FHL

DP 2+ , CRT <2s

Rectal Exam

The RN was in plain view of my exam for the duration; normal external anus and normal tone. No palpable masses, normal mucosa, brown stool.

Pelvic exam

Pelvic Exam (with Female Chaperone):

External: Normal

Vaginal: Normal

Bimanual: Negative