Normal Physical Exam Documentation

Question 1

General appearance

Answer 1

The patient is a well-developed well-nourished male/female resting comfortably in no acute distress.

Question 2

Skin

Answer 2

Warm and dry. Good turgor. No rash, petechiae, or suspicious lesions. No jaundice.

Question 3

Head

Answer 3

Normocephalic, atraumatic. Scalp without lesion. Hair with average texture and normal distribution.

Question 4

Eyes

Answer 4

Visual acuity 20/20 bilaterally. Conjunctiva pink; sclera white. Pupils equal round, reactive to light and accommodation. Extraocular movements intact. Visual fields full by confrontation. Disc margins sharp without hemorrhages or exudates. No arteriolar narrowing or A-V nicking.

Question 5

Ears

Answer 5

Tragus and auricle nontender. Acuity intact to finger rub bilaterally. External auditory canals clear. Tympanic membranes translucent with a good cone of light.

Question 6

Nose

Answer 6

Mucosa pink. Septum midline.

Question 7

Mouth

Answer 7

Moist mucous membranes without lesions. Good dentition. Oropharynx without erythema, tonsillar enlargement, or exudates. Soft palate rises symmetrically. The tongue is midline.

Question 8

Neck

Answer 8

Supple with full range of motion. The trachea is midline. Thyroid without enlargement, nodule, or tenderness.

Question 9

Lymph Nodes

Answer 9

No occipital, posterior auricular, pre-auricular, submandibular, submental, cervical or supraclavicular adenopathy.

Question 10

Thorax and Lungs

Answer 10

Chest wall expansion is symmetrical. Resonant to percussion. Breath sounds vesicular with no added sounds. (Could also write “lungs clear without crackles, wheezes, or rhonchi.)

Question 11

Cardiovascular

Answer 11

PMI in the 5th intercostal space, midclavicular line. Regular rhythm, normal S1 and S2, with physiologic splitting of S2. No murmurs, gallops or rubs. Carotid upstrokes brisk and without bruits bilaterally. Jugular venous pressure 3 cm above sternal angle.

Question 12

Abdomen

Answer 12

Flat, soft, and non-tender with normoactive bowel sounds. No scars or striae. No aortic or renal bruits. No masses. Liver span 7cm in midclavicular line; edge smooth and palpable 1 cm below the right costal margin. No splenomegaly. Aorta width 2 cm.

Question 13

Extremities

Answer 13

No clubbing, cyanosis or edema. Posterior tibial and dorsalis pedis pulses 2+ bilaterally.

Question 14

Musculoskeletal

Answer 14

No obvious joint deformities. Joints without warmth, swelling, or tenderness. Good range of motion in neck, shoulders, elbows, wrists, hands, hips, knees, ankles, and back.

Question 15

Neuro

Answer 15

Mental status: Alert and oriented.

Cranial Nerves:

II: visual acuity 20/20 bilaterally. Visual fields full by confrontation. Pupils are equal, round, and reactive to light and accommodation. Disc margins are sharp.

III, IV and VI: extraocular movements intact.

V: temporal and masseter strength intact, sensation intact to light touch

VII: able to raise eyebrows, squeeze eyelids shut against resistance, puff out cheeks, smile, frown

VIII: hearing intact to finger rub bilaterally

IX, X: palate rises symmetrically, uvula midline

XI: strength of sternocleidomastoid and trapezius 5/5 bilaterally

XII: tongue midline

Reflexes: biceps, triceps, brachioradialis, patellar, ankle reflexes 2+ bilaterally, toes down going on Babinski.

Sensory: light touch, pinprick, vibration and proprioception intact.

Motor: Good bulk and tone. Strength 5/5 throughout.
Coordination: Rapid alternating movements, finger tapping, finger to nose, and heel to shin intact.

Gait: Steady and without ataxia. Able to tandem walk, walk on heels, and walk on toes.

Romberg: Maintains balance with eyes closed

Question 16

Breasts

Answer 16

Symmetric and without erythema, tenderness, skin changes, or masses. Nipples without discharge

Question 17

Genital (female)

Answer 17

External genitalia without erythema or lesions. Vaginal mucosa pink and well rugated and vaginal vault without discharge. Parous cervix without tenderness or discharge. Uterus anterior, midline, and without enlargement. No adnexal tenderness or masses. (Pap smear obtained.)
(Assistant: Jane Smith R.N.)

Question 18

Genital (male)

Answer 18

Circumcised male. No penile discharge or lesions. No scrotal swelling. Testes descended bilaterally, smooth, and without masses. Epididymis non-tender. No inguinal or femoral hernias.

Question 19

Rectal (male)

Answer 19

No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth, non-tender, and without enlargement or nodules. Median sulcus palpable. Stool brown, negative for occult blood.