4. PHYSICAL EXAMINATION

CONSTITUTIONAL:

Height ______ Weight ______ lbs Temperature _______ RA sitting BP ________ LA sitting BP _________

 

RA/LA standing BP _________ RA/LA supine BP _________ Pulse _____ /min reg/irreg Resp. _____ /min.

c Normal General Appearance [including development, nurishment, body habitus, posture, grooming/hygiene]

c Except abnormal for

 

EYES:

c Normal conjunctivae and eyelids.

c Normal pupils and irises, [including PERLA , size, symmetry and no cilliary flush].

c Normal ophthalmoscopy [including bilateral C/D ratio of about 0.6, retinal vasculature, veins pulsating,

pale retina, red mculae, no exudate or hemorrhage].

c Except abnormal for

 

ENMT:

c Normal external inspection of ears and nose [including overall appearance, no scar, lesion or mass].

c Normal otoscopy [including auditory canals, ear drum light reflex, and malleus landmarks].

c Normal hearing [by voice, finger rub, whispering, tuning fork].

c Normal inspection of nasal mucosa, septum, and turbinates.

c Normal inspection of lips, teeth, gums.

c Normal oropharynx [including hydrated mucosa with no lesion, symmetric hard palate, soft palate, tongue,

tonsil, posterior pharynx, and normal salivary glands].

c Except abnormal for

 

NECK:

c Normal Neck [including appearance, tracheal position and no asymmetry, crepitus or mass].

c Normal Thyroid [including no enlagement, mass or tenderness.]

c Except abnormal for

 

RESPIRATORY:

c Normal respiratory effort [including no intercostal, accessory or diaphragmatic muscles movements].

c Normal chest percussion [including no dullness or hyper-resonance]

c Normal chest palpation [including tactile fremitus].

c Normal auscultation [including normal breath sounds, no adventitious sound or pleural rub].

c Except abnormal for

 

CARDIOVASCULAR:

c Normal palpation [including apex impulse and no precordial thrill].

c Normal auscultation of heart [including no murmur, gallop, click, or pericardial rub].

c Normal Carotid, abdominal, femoral, and pedal pulses [including normal amplitutes, no bruit or

pulsatile/expansible abdominal mass].

c Normal extremities [including no edema, varicosity, or calf tenderness].

c Except abnormal for

 

CHEST (BREAST):

c Normal inspection of breasts [including no asymmetry, nipple retraction or discharge].

c Normal palpation of breasts and axillae [including no tenderness, lump, or mass].

c Except abnormal for

 

GASTROINTESTINAL (ABDOMEN):

c Normal abdomen [including soft, non-tender abdomen with no palpable mass].

c Normal liver and spleen.

c Normal abdominal wall [including no scar, abdominal wall or inguinal hernia].

c Normal anus, perineum and rectum [including sphincter tone, no anal lesion, hemorrhoid, rectal stricture,

tenderness, bleeding, mass or fecal impaction].

c Except abnormal for

c Stool sample for occult blood test was obtained.

 

GENITOURINARY (Male):

c Normal scrotal content [including no hydrocele, spermatocele, cord tenderness or testiclular mass].

c Normal penis [circumcised/uncircumcised and no lesion].

c Normal prostate [including nontender, elastic, slightly and vertically convex, with normal size and mobility].

c Except abnormal for

-4-