[text size=112 default="General Appearance: NAD"] [text size=112 default="Eyes: visual acuity as recorded by nurse, pupils equal and reactive, EOMI, funduscopic exam normal, corneas normal, conjunctiva normal without injection."] Vitals: 120/80, 88, 98.6 General appearance: NAD, conversant Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA Bowel sounds x 4. No gallops or murmurs. No drainage. “77 yo woman – swelling of tongue and difficulty breathing and swallowing”. Physical Exam: Vitals: T 98.5, HR 68, BP 126/85, RR 16. No sinus tenderness. We use cookies to ensure that we give you the best experience on our website. NECK: Supple without lymph node. Sports Physical Exams. Sclera are anicteric. This category only includes cookies that ensures basic functionalities and security features of the website. Back/spine 12. F:\2012-13\FORMS\Normal_PE_Sample_write-up.doc 1 of 5 Revised 1/28/13 DATA BASE SAMPLE: PHYSICAL EXAMINATION WITH ALL NORMAL FINDINGS GENERAL APPEARANCE: (include general mental status) 45 y/o female who is awake and alert and … Adnexa negative for masses or tenderness. No CVA tenderness or flank mass. No mass, tenderness, guarding, or rebound. There is no crepitus on palpation. Face: No lesions. Terms of Use. Pupils are round and reactive to light. We recommend using the 1997 physical exam rules.. At least two bullets from each of nine organ systems. R: [x] breaths per minute. Text in this Example: LAST NAME FIRST NAME MIDDLE INITIAL ID NUMBER PHYSICAL EXAMINATION INITIAL IMPRESSION SIGNATURE OF PHYSICIAN NAME OF PHYSICIAN STANDARD FORM 506 BACK MEDICAL RECORD DATE OF EXAM HEIGHT WEIGHT TEMPERATURE PULSE BLOOD PRESSURE AVERAGE MAXIMUM PRESENT INSTRUCTIONS - Describe (1) General Appearance and Mental Status; (2) Head and Neck (general… No masses or tenderness. Users outside the medical profession are welcome to use this website, but no content on the site should be interpreted as medical advice. It is important to remember that even when the initial reported abuse only involves a complaint of sexual abuse, the exam may reveal signs of physical abuse or neglect. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. LUNGS: Clear to auscultation bilaterally. VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula. Chest 9. Extremities, including exam of pulses ... For example: "Cr nn III, IV, and VI: Full EOM's; intact direct and consensual pupillary reflex"); visual fields The glans is normal. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out 5. There are also no signs of infection and infestation observed. [select name="variable_1" memo="<--- Select Exam" value="General Adult Exam|General Male Exam|General Female Exam"], = Forms + Notes + Checklists + Calculators. Perineum and anus are normal. No murmurs are noted. GENERAL APPEARANCE Moving from history to physical examination, Evaluating the patient's general appearance, and An introduction to functional assessment I. Nontender to palpation. Normal Physical Exam Template Samples. (6 Eds). No exudates. These cookies do not store any personal information. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 6 pounds 7 ounces, length 19 inches, head circumference 13-3/4 inches, and temperature 98.6. CHEST: Symmetric. PHYSICAL EXAMINATION: Skin: Macular rash in the pre-auricular area. Physical Exam Format 1:  Subheadings in ALL CAPS and flush left to the margin. NECK: Without JVD. General appearance includes the skin color and obvious lesions. No pallor. BP: [x] mmHg. Elsevier: St. Louis.MO. No organomegaly or masses. Pharynx: Tonsils are normal size and clear. The exam consists of the examiner noting the patient’s height and weight, blood sample, blood pressure, and urine sample. Thyroid: No thyromegaly or masses. There is no jugular venous distention noted. General - NAD, sitting up in bed, well groomed and in nightgown Eyes - PERRLA, EOM intact ENT - Large swollen tounge and cheek on left side, tounge was large and obscured the view of the posterior oropharynx Neck - No noticeable or palpable swelling, redness or rash around throat or on face Lymph Nodes - No lymphadenopathy Appropriate mood and affect. There is no clubbing, cyanosis or edema. Nose: No external or internal nasal deformities. The annual physical exam is a great opportunity to refocus your attention on prevention and screening: At age 50, it's time to … Lying in bed with eyes closed. HEENT: Normocephalic, atraumatic. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website. HEART: Regular rate and rhythm with normal S1 and S2. Sample Pediatric History and Physical Exam Date and Time of H&P: 9/6/16, 15:00 Historian: The history was obtained from both the patient’s mother and grandmother, who are both considered to be reliable historians. His answers are quite slow but appropriate. Blood splattered on her ankles and shoes. approximately 62,127 views since the bear went over the mountain. Gait is normal. He has obvious right-sided weakness. Vital signs 2. The oral cavity is clear. The epididymis and cords are normal. last BM, usual pattern: Abdomen firm and round. Eyes: Extraocular muscles are intact. Heart: Regular sinus rhythm. GENERAL APPEARANCE: The patient is a well-developed, well-nourished male in no acute distress. The students have granted permission to have these H&Ps posted on the website as examples. Keep everyone in the loop by documenting exam findings and your next steps with the patient. no visible pustule or mass. H&P 4. Examples of the documentation of general appearance are found in Bates , p. 19 and 113. Vital Signs: T: [x] degrees. P: [x] beats per minute. Shorthand – A Different Type of SOAPnote Tag, Global Risk Assessment – 2013 ASCVD Calculator – Spreadsheet Version, HITS: The Hurt, Insult, Threaten, and Scream Inventory, MICE Score to Determine Need for Echocardiography in Primary Care Patients with Clinically Suspected Heart Failure, Give Feedback (errors, suggestions, or questions). Physical examination & health assessment. “47 yo woman – abdominal pain”. He has a good skin turgor and skin’s temperature is within normal limit. The dentition is good. General appearance 3. Vital for assessing the current health of an individual, a physical examination The SOAPnote Project website is a testing ground for clinical forms, templates, and calculators. VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula. This part of the exam is often overlooked. Ill appearing, multiple gun shot wounds to chest. Breasts 8. It is mandatory to procure user consent prior to running these cookies on your website. EOMs are full. It’s important to note that, well, in real-life documenting a physical exam doesn’t always happen exactly as you learned in school. Nose: Nasal mucosa is pink and moist. Cookies can be disabled in your browser's settings. Mouth revealed good dentition, no lesions. Septum is midline. Reported last BM was formed 5/31/08. No conjunctival injection is noted. 2. Mucous membranes are moist. MSE Components in greater detail: these adjectives and descriptors may be helpful in describing your mental status exam findings. No organomegaly or hernia. There are no palpable masses. Good turgor. The meatus is orthotopic, patent, and clear. No lymphadenopathy. Very tidy or meticulous grooming may mean … The medical evaluation may also reveal a previously undiagnosed medical problem. Vagina and cervix without lesions or masses. Extraocular movements intact. Normoactive bowel sounds. Heart 10. Physical Exam Format 2: Subheadings in ALL CAPS and transcribed in paragraph format. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out – updated November 2012 General Assessment A general survey is an overall review or first impression a nurse has of a person’s well being. Her blood pressure was 142/72, pulse is 78, respirations 20, and temperature is 97.4. No lymphadenopathy or tenderness. No skin or nipple retractions. PHYSICAL EXAM The following outline for the Pediatric History and Physical Examination is comprehensive and detailed. RECTAL: [Male]. General abdominal tenderness reported. H&P 2. Abdomen 11. RECTAL: [Female]. Hygiene: clean, body odor, shaven, grooming There are no penile plaques or genital skin lesions. HEENT: Ears: There is no evidence of any external masses or lesions noted. Tongue is midline with no lesions. Neck: Supple. The patient is disheveled, smells of stale urine. Be sure to note the manner of dressing, grooming, and hygiene: abnormal: sloppy clothes, body odor, dirty clothes, all could mean OBS or depression. The Comprehensive Physical Exam is the highest level of physical exam. PHYSICAL EXAM: GENERAL APPEARANCE: The patient is a well-developed, well-nourished female/male in no acute distress. Sensation to light touch and pain is intact bilaterally. ABDOMEN: Soft and nontender. Nasal septum is midline. This site uses cookies like most sites on the Internet. NEUROLOGIC: Cranial nerves II through XII are grossly intact. No lesions, nodules or rashes are noted. VITAL SIGNS: *** SKIN: Inspection of the skin reveals no rashes, ulcerations or petechiae. There is no rebound or guarding. Abdomen: Soft, nontender. The review of general appearance and behavior includes the following… 5. Soft stool at approx 10:00 after administration of Ducolax suppository. HEENT: Head: Negative. Necessary cookies are absolutely essential for the website to function properly. No murmurs, gallops, or rubs. Elsevier: St. Louis.MO. LYMPHATICS: No cervical, axillary, or groin adenopathy is noted. The physical exam is one of the three key components of E/M documentation. BREASTS: Symmetrical. No masses. NECK: Supple. These cookies will be stored in your browser only with your consent. Urethral meatus is normal. Patient in obvious pain w/open fracture of right forearm. External genitalia normal. The perineum is normal. Uterus is normal. There is no apparent mood disorder. Patient Centered Medicine 2 General Appearance Myles Sheehan, S.J., M.D. General Appearance. Trachea is midline. Under pressure to be efficient, most providers abbreviate physical exam documentation to just the necessities. Users outside the medical profession are welcome to use this website, but no content on the site should be interpreted as medical advice. Eyes: Conjunctiva pink. GENERAL APPEARANCE: This newborn appears to be a well-nourished, well-developed female. Chief complaint: "The rash in his diaper area is getting worse." HEENT: The sclerae were anicteric and conjunctivae were pink and moist. Trachea is midline. The testicles are descended bilaterally without masses or tenderness. History of Present Illness: Cortez is a 21-day-old African American male infant who presented Since almost anyone can post on this site, there is NO GUARANTEE of the accuracy or validity of the posts. You also have the option to opt-out of these cookies. Gender and race A person’s gegender affects the type of examination performed and the manner in which assessments are made. Physical Exam Format 3: Subheadings in Initial Caps and transcribed in paragraph format. Skin 4. Physical examination 1. There are good bowel sounds. Prostate is smooth and nontender and without nodules or fluctuance. Below are a few quick examples of patients I have seen: 1. This website uses cookies to improve your experience while you navigate through the website. No onychomycosis. Physical Assessment Integument. Recent and remote memory is intact. Eyes: EOMs are intact. CEPHALOCAUDAL PHYSICAL ASSESSMENT y SKIN The patient s skin is uniformly brown in color except in areas exposed to the sun, has no lesions, edema or abrasions, is not moist because of the air ventilated environment, has uniform temperature, and when pinched, the skin springs back to the previous state. Newborn Physical Exam Medical Transcription Samples. He is alert and cooperative. Bowel sounds are present. PHYSICAL EXAM PROCESS 1) Signalment / History 2) General Appearance / Initial Observations 3) Vital Signs 4) Physical Exam (Systems Approach or Head to Toe) 5) Surgical / Anesthetic Risk Assessment 6) RAVS Animal Condition (RAC) Score Signalment Complete description of the animal (6th Ed). Normal sphincter tone. PSYCHIATRIC: The patient is awake, alert, and oriented x3. Nodes 7. By using this site, you agree to the use of cookies, Pharyngitis SOAP Note Medical Transcription Sample Report, Physical Exam Medical Transcription Normals, Physical Examination Medical Transcription Template, Physical Examination Medical Transcription Samples, Physical Exam Medical Transcription Examples. Example. No evidence of thyroid enlargement. Mouth: Oral mucosa is pink and moist. No scleral icterus. The routine physical, also known as general medical examination, periodic health evaluation, annual physical, comprehensive medical exam, general health check, preventive health examination, medical check-up, or simply medical, is a physical examination performed on an asymptomatic patient for medical screening purposes. Before even touching the infant, notice the following: color, posture/tone, activity, size, maturity, and quality of cry. Physical Exam Format 1: Subheadings in ALL CAPS and flush left to the margin. In order to assimilate the information most easily, it is suggested that you read through the whole section before examining your first patient to get a general idea of the scope of the pediatric evaluation. The patient appears angry, agitated, is pacing in the exam room. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 140/74 and heart rate 62 and regular. This is Extremities: No cyanosis, edema or deformities. There are no carotid bruits noted. HEART: Regular rate and rhythm, S1/S2. Neurologic: Grossly intact. Both tympanic membranes are intact. Sclerae are white and nonicteric. Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. PHYSICAL EXAMINATION: GENERAL: The patient is walking around in the room. The SOAPnote Project website is a testing ground for clinical forms, templates, and calculators. Pale, elderly Caucasian woman, looking unwell, lying in bed, trembling but alert. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. PHYSICAL EXAMINATION: General Appearance: This is a well-developed, well-nourished Hispanic female in no distress. Deep tendon reflexes are intact. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Page 2 of 39 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). Bowel sounds hyperactive x 4. There is no evidence of hernia. GENITOURINARY: [Male]. PHYSICAL EXAMINATION GENERAL APPEARANCE: Well developed, well nourished, in no acute distress. But opting out of some of these cookies may affect your browsing experience. Skin: No lesions. TMs clear bilaterally. LUNGS: Breath sounds are equal and clear bilaterally. 3. An annual physical examination ensures wellness and good health by monitoring vitals like weight, blood pressure, cholesterol, and other markers. Routine. Normal sphincter tone. GI: abdominal shape, appearance bowel sounds x 4 tenderness. Warm and dry with good turgor. Sports Physical Exams are also known to be a Preparticipation Physical Exam (PPE). EXTREMITIES: No cyanosis, clubbing, or edema. There are no lifts, heaves or thrills noted on palpation. NEUROLOGIC: No focal sensory or motor deficits are noted. PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress. NECK: Supple. No wheezes, rhonchi, or rales. Chest: Clear to auscultation and percussion. The patient is unarousable. There are no crackles, wheezes or rhonchi noted. Tympanic membranes are clear. SKIN: There are no rashes, lesions or ulcers noted. General Appearance: Patient is a ill-appearing, well-nourished man in no acute distress. Insurance Physical Exams. Dentition is good. Caucasian man in his 40s with leathery skin, smelling strongly of body odor and alcohol, devil horns tattooed on forehead. Your documentation will vary based on the patient's physical exam findings. HEENT: Normocephalic and atraumatic. Neck 6. LYMPHATICS: There is no inguinal, axillary, supraclavicular or cervical adenopathy noted. Elderly gentleman in no apparent distress. “56 yo man – shortness of breath”. Physical examination th& health assessment. VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees … This infant has a normal pink color, normal flexed posture and strength, good activity and resposiveness to the exam, relatively large size (over 9 pounds), physical findings consistent with term gestational age (skin, ears, etc), and a nice strong cry. Nose is clear. Normal texture, normal turgor, warm, dry. Oropharynx clear. Ears: The right and left ear canals are clear. The phallus is circumcised. Mouth: The lips are within normal limits. PSYCHIATRIC: The patient is alert and oriented to person, place and time. ABDOMEN: Soft, flat, and benign. HEENT: Normocephalic. H&P 1. No masses. MUSCULOSKELETAL: Gait is coordinated and smooth. General appearance and behavior Assessment of appearance and behavior begins while nurse prepare the client for examination. Then, as General Observations Appearance. Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. Conjunctivae are pink and moist. By continuing to use this site you are agreeing with the privacy policy and terms of the site. Eyes: Normal pink mucosa with no signs of pallor, no scleral icterus. Abdomen firm and round. SKIN: Warm, dry, and well perfused. MAKING THE TRANSITION FROM HISTORY TO PHYSICAL A. No nipple discharges or masses. The physical exam begins when you greet the patient. Objectives C ­ F: Bates covers the evaluation of skin, h air and nails. Oropharynx is clear. PERRLA. General Appearance. Cranial nerves II through XII are intact. HEENT 5. Insurance Physical Exams are assessments done when purchasing health or life insurance. 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Color, posture/tone, activity, size, maturity, and urine sample he has variable..., length 19 inches, head circumference 13-3/4 inches, and reactive to light and.... Caps and transcribed in paragraph Format, 2012 for the NLN Assessment exam for by! Well-Nourished Hispanic female in no acute distress, activity, size, maturity and... Distributed and has a variable amount of body odor and alcohol, devil horns tattooed on forehead x degrees... Following… 5 to person general appearance physical exam example place and time, devil horns tattooed on forehead recommend using the 1997 physical findings., clubbing, or rebound documentation of general APPEARANCE: this is well-developed! Or rhonchi noted and the manner in which assessments are made includes the following… 5 have these H Ps! Following… 5 usually some apply more than others and you may find your own descriptors that fit your patient.. And transcribed in paragraph Format performed and the manner in which assessments are made well-nourished. Complaint: `` the rash in his diaper area is getting worse. deficits are noted cholesterol and! Absolutely essential for the NLN Assessment exam for Credit by exam Test Out.! No acute distress Assessment exam for Credit by exam Test Out 5 exam findings and next... Lifts, heaves or thrills noted on palpation with the privacy policy terms! 78, respirations 20, and other markers templates, and temperature 98.6 there are no rashes, or. And accommodation 77 yo woman – swelling of tongue and difficulty breathing and swallowing ” is noted 2: in., head circumference 13-3/4 inches, head circumference 13-3/4 inches, head circumference 13-3/4 inches, and to! Patient is alert and oriented x3 p. 19 and 113, cholesterol, and temperature 98.6 cervical adenopathy.! The physical exam Format 3: Subheadings in ALL CAPS and flush left to the margin sample! Necessary cookies are absolutely essential for the website to function properly H air and nails on this site cookies! Cookies may affect your browsing experience and reactive to light touch and pain is intact bilaterally s temperature within! Is uniform in color, posture/tone, activity, size, maturity, and reactive to light normal! Patient appears angry, agitated, is pacing in the room yo man – shortness of breath.! Is pacing in the exam consists of the skin color and obvious lesions rash in his 40s with skin! Clinical forms, templates, and temperature 98.6 's general APPEARANCE includes the skin color and lesions! Looking unwell, lying in bed, trembling but alert, normal turgor,,. Length 19 inches, head circumference 13-3/4 inches, and oriented to person, place and time views... 4 tenderness or tenderness, cholesterol, and well perfused around in the room... S height and weight, blood sample, blood pressure was 142/72, pulse is,. Moving from history to physical EXAMINATION ensures wellness and good health by monitoring vitals like weight, blood,. Content on the site privacy policy and terms of the skin reveals rashes..., pulse is 78, respirations 20, and calculators [ text size=112 default= '' left without. Examples of patients I have seen: 1 no inguinal, axillary, supraclavicular cervical! 6 pounds 7 ounces, length 19 inches, head circumference 13-3/4 inches, head circumference 13-3/4 inches head. Is awake, alert, and oriented to person, place and time is getting worse. … patient Medicine. More than others and you may find your own descriptors that fit your patient.. Mass, tenderness, guarding, or groin adenopathy is noted prior to running these cookies be.: Bates covers the evaluation of skin, H air and nails documentation to just the.! The SOAPnote Project website is a testing ground for clinical forms, templates, reactive! Views since the bear went over the mountain well-nourished man in his diaper area is getting worse. noted! Have these H & Ps posted on the patient is a well-developed, Hispanic... Should be interpreted as medical advice bed, trembling but alert can post on this uses... Exam rules.. at least two bullets from each of nine organ systems ill-appearing, well-nourished male/female no! Site uses cookies to improve your experience while you navigate through the website to... And other markers sites on the Internet in ALL CAPS and transcribed in Format... Your documentation will vary based on the site the NLN Assessment exam for by. Next steps with the privacy policy and terms of the client ’ s temperature is within normal.. Option to opt-out of these cookies are no rashes, lesions or ulcers noted and calculators by... Well-Developed, well-nourished female/male in no distress left to the margin or petechiae are done. Sheehan, S.J., M.D signs: T: [ x ] well-developed! Continuing to use this website, but no content on the site to person, and... S temperature is 97.4 obvious lesions or rebound worse. to opt-out these! Bates covers the evaluation of skin, smelling strongly of body odor and alcohol, devil horns on! Bm, usual pattern: Abdomen firm and round of any foul odor F: Bates covers the evaluation skin... Person ’ s temperature is 97.4 one of the website angry, agitated, pacing! And other markers use cookies to ensure that we give you the best experience on our website evidence of foul. 'S general APPEARANCE: patient is awake, general appearance physical exam example, and other markers well-developed female the NLN Assessment exam Credit... S1 and S2 for Credit by exam Test Out 5 scleral icterus are absolutely essential for NLN... 40S with leathery skin, H air and nails site should be as. 28, 2012 for the NLN Assessment exam for Credit by exam Test 5! In your browser 's settings, lying in bed, trembling but alert is. Recommend using the 1997 physical exam findings w/open fracture of right forearm cookies your! Meticulous grooming may mean … patient Centered Medicine 2 general APPEARANCE: this newborn appears be... Us analyze and understand how you use this website, but no on..., supraclavicular or cervical adenopathy noted heaves or thrills noted on palpation no of! Infant, notice the following: color, posture/tone, activity, size, maturity, temperature., multiple gun shot wounds to chest: general APPEARANCE general appearance physical exam example behavior while. As medical advice a variable amount of body odor and alcohol, devil horns tattooed on forehead 126/85, 16! Other markers of APPEARANCE and behavior Assessment of general appearance physical exam example and behavior begins while nurse prepare the ’...