Normal physical exam note

Question 1

HEENT

Answer 1

normocephalic / atraumatic, nontender. PERRLA. Fundi - red reflex intact. EOMI. TMs, pharynx - WNL. No nasal discharge. Lymph gladns, thyroid not enlarged.

Question 2

Cardiac

Answer 2

s1, s2- wnl, regular rate & rhythm. No rub/gallop/murmur sitting and supine. No JVD. PMI not displaced. No clubbing, edema. Carotid, radial, DP, PT pulse NL & equal B/L. No carotid bruits.

Question 3

Abdomen

Answer 3

normal appearance, BS+ all 4 quadrants, no bruits heard, tympanic all 4 quadrants, liver size - 10 cm. No tenderness or masses to light or deep palpation 4 quadrants. No CVA pain. Neg Murphy’s.

Question 4

Neurologic

Answer 4

A&Ox3, CN 2-7, 9,10,12 NL. Sensation intact all 4 ext to light touch. Position sense and vibration sense NL B/L lower ext. Motor 5/5 all 4 ext. DTR 2/4 brachial, patella, B/L. Gait - WNL. No Kernig or Brudzinski. Neck supple. Straight leg test negative B/L. Romberg negative. Babinski- down going toes B/L.

Question 5

Chest

Answer 5

Chest appears NL, nontender, NL resp. excursion, fremitis, percussion NL and equal B/L. Lungs clear to auscultation.