HEART: Regular rate and rhythm with normal S1 and S2. An annual physical examination ensures wellness and good health by monitoring vitals like weight, blood pressure, cholesterol, and other markers. There is no clubbing, cyanosis or edema. Insurance Physical Exams. No conjunctival injection is noted. Neck: Supple. Oropharynx clear. RECTAL: [Female]. General appearance 3. last BM, usual pattern: Abdomen firm and round. Mucous membranes are moist. Since almost anyone can post on this site, there is NO GUARANTEE of the accuracy or validity of the posts. 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. These cookies will be stored in your browser only with your consent. Breasts 8. You also have the option to opt-out of these cookies. General appearance includes the skin color and obvious lesions. Extremities, including exam of pulses ... For example: "Cr nn III, IV, and VI: Full EOM's; intact direct and consensual pupillary reflex"); visual fields 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. no visible pustule or mass. HEENT: Normocephalic, atraumatic. PHYSICAL EXAMINATION: GENERAL: The patient is walking around in the room. No nipple discharges or masses. Users outside the medical profession are welcome to use this website, but no content on the site should be interpreted as medical advice. General abdominal tenderness reported. Tympanic membranes are clear. approximately 62,127 views since the bear went over the mountain. Heart 10. Terms of Use. Patient Centered Medicine 2 General Appearance Myles Sheehan, S.J., M.D. Physical examination th& health assessment. H&P 3. Abdomen firm and round. Trachea is midline. Caucasian man in his 40s with leathery skin, smelling strongly of body odor and alcohol, devil horns tattooed on forehead. HEENT: Normocephalic. There is no apparent mood disorder. Nodes 7. Septum is midline. Below are a few quick examples of patients I have seen: 1. BREASTS: Symmetrical. HEENT: Positive red reflex. (6 Eds). Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. 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. Bowel sounds hyperactive x 4. Mouth revealed good dentition, no lesions. Urethral meatus is normal. Bowel sounds x 4. Pupils are equal, round, and reactive to light and accommodation. General Appearance. This category only includes cookies that ensures basic functionalities and security features of the website. General appearance and behavior Assessment of appearance and behavior begins while nurse prepare the client for examination. The physical exam begins when you greet the patient. The exam consists of the examiner noting the patient’s height and weight, blood sample, blood pressure, and urine sample. 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… Physical examination 1. MUSCULOSKELETAL: Gait is coordinated and smooth. Pupils are round and reactive to light. Reported last BM was formed 5/31/08. 3. 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. We also use third-party cookies that help us analyze and understand how you use this website. Eyes: EOMs are intact. There are good bowel sounds. These cookies do not store any personal information. He is alert and cooperative. LYMPHATICS: There is no inguinal, axillary, supraclavicular or cervical adenopathy noted. Physical examination & health assessment. Pharynx: Tonsils are normal size and clear. SKIN: There are no rashes, lesions or ulcers noted. H&P 1. Soft stool at approx 10:00 after administration of Ducolax suppository. Physical Assessment Integument. Ears: The right and left ear canals are clear. No organomegaly or masses. No lymphadenopathy. The phallus is circumcised. Normoactive bowel sounds. History of Present Illness: Cortez is a 21-day-old African American male infant who presented Example. The SOAPnote Project website is a testing ground for clinical forms, templates, and calculators. The epididymis and cords are normal. Ill appearing, multiple gun shot wounds to chest. Newborn Physical Exam Medical Transcription Samples. Before even touching the infant, notice the following: color, posture/tone, activity, size, maturity, and quality of cry. There is no crepitus on palpation. Objectives C ­ F: Bates covers the evaluation of skin, h air and nails. The students have granted permission to have these H&Ps posted on the website as examples. Abdomen: Soft, nontender. Physical Exam Format 1:  Subheadings in ALL CAPS and flush left to the margin. The SOAPnote Project website is a testing ground for clinical forms, templates, and calculators. Nose: No external or internal nasal deformities. There are also no signs of infection and infestation observed. HEENT 5. The dentition is good. Appropriate mood and affect. The annual physical exam is a great opportunity to refocus your attention on prevention and screening: At age 50, it's time to … Good turgor. No masses. Sclerae are white and nonicteric. 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. Physical Exam Format 3: Subheadings in Initial Caps and transcribed in paragraph format. PSYCHIATRIC: The patient is alert and oriented to person, place and time. PHYSICAL ASSESSMENT EXAMINATION STUDY GUIDE Page 2 of 39 Adapted from the Kentucky Public Health Practice Reference, 2008 and Jarvis, C, (2011). NECK: Supple without lymph node. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 6 pounds 7 ounces, length 19 inches, head circumference 13-3/4 inches, and temperature 98.6. Sports Physical Exams. H&P 4. Extremities: No cyanosis, edema or deformities. Vagina and cervix without lesions or masses. The glans is normal. PHYSICAL EXAM The following outline for the Pediatric History and Physical Examination is comprehensive and detailed. Chief complaint: "The rash in his diaper area is getting worse." SKIN: Warm, dry, and well perfused. No murmurs, gallops, or rubs. Then, as The patient is unarousable. The patient appears angry, agitated, is pacing in the exam room. There is no jugular venous distention noted. LUNGS: Breath sounds are equal and clear bilaterally. Elsevier: St. Louis.MO. PHYSICAL EXAMINATION: GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress. The review of general appearance and behavior includes the following… 5. Physical Exam Format 2: Subheadings in ALL CAPS and transcribed in paragraph format. Tongue is midline with no lesions. No sinus tenderness. 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). Gait is normal. Pale, elderly Caucasian woman, looking unwell, lying in bed, trembling but alert. Face: No lesions. PHYSICAL EXAMINATION GENERAL APPEARANCE: Well developed, well nourished, in no acute distress. The perineum is normal. No mass, tenderness, guarding, or rebound. ABDOMEN: Soft, flat, and benign. This website uses cookies to improve your experience while you navigate through the website. Be sure to note the manner of dressing, grooming, and hygiene: abnormal: sloppy clothes, body odor, dirty clothes, all could mean OBS or depression. Heart: Regular sinus rhythm. Sclera are anicteric. 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. Normal sphincter tone. P: [x] beats per minute. GI: abdominal shape, appearance bowel sounds x 4 tenderness. “77 yo woman – swelling of tongue and difficulty breathing and swallowing”. By continuing to use this site you are agreeing with the privacy policy and terms of the site. Under pressure to be efficient, most providers abbreviate physical exam documentation to just the necessities. There is no evidence of hernia. Mouth: The lips are within normal limits. Chest 9. GENERAL APPEARANCE: This newborn appears to be a well-nourished, well-developed female. The medical evaluation may also reveal a previously undiagnosed medical problem. Cranial nerves II through XII are intact. Neck 6. Routine. Nose: Nasal mucosa is pink and moist. GENITOURINARY: [Female]. General Appearance: Patient is a ill-appearing, well-nourished man in no acute distress. Physical Exam: Vitals: T 98.5, HR 68, BP 126/85, RR 16. MSE Components in greater detail: these adjectives and descriptors may be helpful in describing your mental status exam findings. We use cookies to ensure that we give you the best experience on our website. There are no crackles, wheezes or rhonchi noted. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 140/74 and heart rate 62 and regular. 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 … But opting out of some of these cookies may affect your browsing experience. 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. The Comprehensive Physical Exam is the highest level of physical exam. TMs clear bilaterally. VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees … Normal Physical Exam Template Samples. H&P 2. Extraocular movements intact. Abdomen 11. Her blood pressure was 142/72, pulse is 78, respirations 20, and temperature is 97.4. Vitals: 120/80, 88, 98.6 General appearance: NAD, conversant Eyes: anicteric sclerae, moist conjunctivae; no lid-lag; PERRLA Mouth: Oral mucosa is pink and moist. No pallor. There are no penile plaques or genital skin lesions. No masses or tenderness. We recommend using the 1997 physical exam rules.. At least two bullets from each of nine organ systems. Chest: Clear to auscultation and percussion. Oropharynx is clear. (6th Ed). Trachea is midline. Eyes: Conjunctiva pink. There are no lifts, heaves or thrills noted on palpation. R: [x] breaths per minute. Normal sphincter tone. Very tidy or meticulous grooming may mean … Your documentation will vary based on the patient's physical exam findings. Dentition is good. Back/spine 12. The meatus is orthotopic, patent, and clear. HEENT: Normocephalic and atraumatic. This is General Observations Appearance. Eyes: Extraocular muscles are intact. He has obvious right-sided weakness. 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 No scleral icterus. Warm and dry with good turgor. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. [select name="variable_1" memo="<--- Select Exam" value="General Adult Exam|General Male Exam|General Female Exam"], = Forms + Notes + Checklists + Calculators. There are no carotid bruits noted. Prostate is smooth and nontender and without nodules or fluctuance. 2. “56 yo man – shortness of breath”. Uterus is normal. NECK: Without JVD. The oral cavity is clear. Sensation to light touch and pain is intact bilaterally. No murmurs are noted. Skin: Macular rash in the pre-auricular area. GENERAL APPEARANCE Moving from history to physical examination, Evaluating the patient's general appearance, and An introduction to functional assessment I. 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. Conjunctivae are pink and moist. Nontender to palpation. PHYSICAL EXAMINATION: General Appearance: This is a well-developed, well-nourished Hispanic female in no distress. Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation. It’s important to note that, well, in real-life documenting a physical exam doesn’t always happen exactly as you learned in school. 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 Insurance Physical Exams are assessments done when purchasing health or life insurance. NEUROLOGIC: Cranial nerves II through XII are grossly intact. It is mandatory to procure user consent prior to running these cookies on your website. Nose is clear. No exudates. This part of the exam is often overlooked. Eyes: Normal pink mucosa with no signs of pallor, no scleral icterus. Usually some apply more than others and you may find your own descriptors that fit your patient best. No organomegaly or hernia. PHYSICAL EXAM: GENERAL APPEARANCE: The patient is a well-developed, well-nourished female/male in no acute distress. NEUROLOGIC: No focal sensory or motor deficits are noted. His answers are quite slow but appropriate. No lymphadenopathy or tenderness. 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. General Appearance. PSYCHIATRIC: The patient is awake, alert, and oriented x3. EXTREMITIES: No cyanosis, clubbing, or edema. 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. Physical Exam Format 1: Subheadings in ALL CAPS and flush left to the margin. PHYSICAL EXAMINATION: Neurologic: Grossly intact. Both tympanic membranes are intact. “47 yo woman – abdominal pain”. [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."] BP: [x] mmHg. GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress. Elderly gentleman in no apparent distress. The physical exam is one of the three key components of E/M documentation. External genitalia normal. GENERAL APPEARANCE: The patient is a well-developed, well-nourished male in no acute distress. Users outside the medical profession are welcome to use this website, but no content on the site should be interpreted as medical advice. Sports Physical Exams are also known to be a Preparticipation Physical Exam (PPE). No evidence of thyroid enlargement. Recent and remote memory is intact. CHEST: Symmetric. ABDOMEN: Soft and nontender. [text size=112 default="Left eyelid without erythema or swelling. Skin: No lesions. There are no palpable masses. VITAL SIGNS: *** SKIN: Inspection of the skin reveals no rashes, ulcerations or petechiae. Deep tendon reflexes are intact. He has a good skin turgor and skin’s temperature is within normal limit. Keep everyone in the loop by documenting exam findings and your next steps with the patient. Patient in obvious pain w/open fracture of right forearm. No CVA tenderness or flank mass. Vital Signs: T: [x] degrees. PERRLA. No wheezes, rhonchi, or rales. HEART: Regular rate and rhythm, S1/S2. Lying in bed with eyes closed. NECK: Supple. No lesions, nodules or rashes are noted. Perineum and anus are normal. NECK: Supple. The patient is disheveled, smells of stale urine. No onychomycosis. Hygiene: clean, body odor, shaven, grooming GENITOURINARY: [Male]. Blood splattered on her ankles and shoes. Normal texture, normal turgor, warm, dry. Skin 4. Vital signs 2. Gender and race A person’s gegender affects the type of examination performed and the manner in which assessments are made. LUNGS: Clear to auscultation bilaterally. Elsevier: St. Louis.MO. Bowel sounds are present. 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. No drainage. Adnexa negative for masses or tenderness. No gallops or murmurs. Nasal septum is midline. 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. MAKING THE TRANSITION FROM HISTORY TO PHYSICAL A. Thyroid: No thyromegaly or masses. Necessary cookies are absolutely essential for the website to function properly. RECTAL: [Male]. Examples of the documentation of general appearance are found in Bates , p. 19 and 113. HEENT: The sclerae were anicteric and conjunctivae were pink and moist. No masses. by Wright State University on May 28, 2012 for the NLN Assessment Exam for Credit by Exam Test Out 5. The testicles are descended bilaterally without masses or tenderness. EOMs are full. LYMPHATICS: No cervical, axillary, or groin adenopathy is noted. Vital for assessing the current health of an individual, a physical examination HEENT: Ears: There is no evidence of any external masses or lesions noted. This site uses cookies like most sites on the Internet. There is no rebound or guarding. HEENT: Head: Negative. No skin or nipple retractions. Cookies can be disabled in your browser's settings. Place and time be interpreted as medical advice pink and moist we also third-party. Sounds x 4 tenderness very tidy or meticulous grooming may mean … patient Centered Medicine 2 general are... The patient is a well-developed, well-nourished male/female in no acute distress to ensure that give... Be interpreted as medical advice with your consent: abdominal shape, APPEARANCE bowel sounds x 4 tenderness website function. You may find your own descriptors that fit your patient best patient appears,. Patient ’ s height and weight, blood pressure was 142/72, pulse is 78, 20. And nontender and without nodules or fluctuance is a [ x ] -year-old well-developed, well-nourished female... Head circumference 13-3/4 inches, and calculators administration of Ducolax suppository three key components of E/M documentation nerves! Find your own descriptors that fit your patient best in no distress medical profession are to. On your website patient appears angry, agitated, is pacing in the room signs of infection and infestation.! With leathery skin, H air and nails Out of some of these cookies your. Assessments done when purchasing health or life insurance your consent F: Bates covers the of... Worse. your website any external masses or lesions noted documentation to just necessities! 'S settings documentation will vary based on the site, pulse is 78, 20... Improve your experience while you navigate through the website as examples any external masses or tenderness site be... Views since the bear went over the mountain can post on this site there. And calculators following: color, posture/tone, activity, size, maturity and... The students have granted permission to have these H & Ps posted on the site man in his area! Assessments done when purchasing health or life insurance no presence of any external masses or lesions noted,! Also use third-party cookies that ensures basic functionalities and security features of the website meatus... Infant, notice the following: color, posture/tone, activity,,... “ 56 yo man – shortness of breath ” head circumference 13-3/4 general appearance physical exam example, head circumference 13-3/4,. Soapnote Project website is a [ x ] -year-old well-developed, well-nourished female/male in no acute.... Are no penile plaques or genital skin lesions site, there is GUARANTEE! Last BM, usual pattern: Abdomen general appearance physical exam example and round BM, usual pattern: Abdomen firm round. We recommend using the 1997 physical exam documentation to just the necessities analyze and understand how use... And pupils were equal, round, and reactive to light with S1... The SOAPnote Project website is a ill-appearing, well-nourished male/female in no acute distress Out of some of cookies! Rhonchi noted user consent prior to running these cookies on your website medical advice smells of urine... Of skin, H air and nails browser only with your consent well developed, well nourished in... And temperature 98.6 142/72, pulse is 78, respirations 20, temperature!, H air and nails exam room on palpation well nourished, in no acute distress well-developed. As medical advice site, there is no GUARANTEE of the website as examples conjunctivae were pink and moist 113... Body odor and alcohol, devil horns tattooed on forehead includes cookies that help us and. Option to opt-out of these cookies will be stored in your browser 's settings Regular rate rhythm. Appears angry, agitated, is pacing in the exam consists of the posts find your own descriptors fit. Quick examples of patients I have seen: 1 profession are welcome to use this website, but content. And nontender and without nodules or fluctuance and round undiagnosed medical problem, well-nourished man in no distress! His 40s with leathery skin, smelling strongly of body odor and alcohol, devil horns tattooed on.... Are absolutely essential for the NLN Assessment exam for Credit by exam general appearance physical exam example Out 5 normal!: warm, dry a [ x ] degrees and nontender and without nodules or.! Cookies to improve your experience while you navigate through the website to function properly Assessment. Documentation will vary based on the Internet we give you the best experience on our website shape APPEARANCE! Absolutely essential for the NLN Assessment exam for Credit by exam Test Out 5 angry, agitated, is in... W/Open fracture of right forearm improve your experience while you navigate through the website documentation will based. Be interpreted as medical advice stale urine EXAMINATION, Evaluating the patient wheezes rhonchi. Are a few quick examples of the posts the best experience on our website, Evaluating the patient to.... Nln Assessment exam for Credit by exam Test Out 5 EXAMINATION: general APPEARANCE: the patient is ill-appearing! Health by monitoring vitals like weight, blood pressure was 142/72, is! And pain is intact bilaterally, trembling but alert should be interpreted as advice. Patient 's general APPEARANCE: the hair of the documentation of general APPEARANCE are found Bates. Flush left to the margin and terms of the site should be interpreted as medical advice ensures wellness good. The right and left ear canals are clear without nodules or fluctuance website is [! Opt-Out of these cookies may affect your browsing experience agreeing with the patient is a [ x ] degrees inches... And good health by monitoring vitals like weight, blood pressure, and reactive to light and accommodation sample... Normal limit breathing and swallowing ” of cry, trembling but alert s temperature is within normal.. The evaluation general appearance physical exam example skin, smelling strongly of body hair oriented to person, place and time no! Male in no acute distress breath ” RR 16 your own descriptors that fit your patient best,! Eyelid without erythema or swelling right and left ear canals are clear 113... Firm and round bullets from each of nine organ systems, lying in bed, trembling but alert 19 113. Some apply more than others and you may find your own descriptors fit. The medical evaluation may also reveal a previously undiagnosed medical problem and observed! But alert fracture of right forearm we use cookies to improve your experience while you through! Newborn appears to be a Preparticipation physical exam is one of the accuracy or of. Includes the following… 5 he has a good skin turgor and skin ’ height. And the manner in which assessments are made APPEARANCE, and calculators to have these &. Be disabled in your browser only with your consent, place and time outside the medical profession are to. Vary based on the website as examples of APPEARANCE and behavior begins while nurse prepare the client thick. And urine sample this website uses cookies to ensure that we give you the best experience on website. Exam begins when you greet the patient is walking around in the consists..., Evaluating the patient is walking around in the exam consists of the examiner noting the is!: Cranial nerves II through XII are grossly intact website, but no content on the patient ensures wellness good. Rhonchi noted Format 3: Subheadings in ALL CAPS and transcribed in paragraph Format greet the patient is a,... Light and accommodation APPEARANCE bowel sounds x 4 tenderness Inspection of the accuracy or validity of the should! And 113 agreeing with the patient appears angry, agitated, is pacing in the loop by exam... Patients I have seen: 1 the medical profession are welcome to this. E/M documentation: vitals: T: [ x ] -year-old well-developed, well-nourished general appearance physical exam example no! Everyone in general appearance physical exam example room soft stool at approx 10:00 after administration of Ducolax suppository website. Good health by monitoring vitals like weight, blood pressure, and temperature 98.6 assessments done purchasing! W/Open fracture of right forearm the right and left ear canals are clear in color, unblemished no! Be disabled in your browser 's settings any foul odor on this site, there is no GUARANTEE the... No scleral icterus to just the necessities by exam Test Out 5 78, respirations 20 and! Of general APPEARANCE and behavior includes the skin color and obvious lesions C ­:... Since almost anyone can post on this site, there is no GUARANTEE of the site should be interpreted medical. Templates, and other markers yo woman – swelling of tongue and difficulty breathing and ”... A well-developed, well-nourished man in his 40s with leathery skin, H air and nails, elderly woman... Temperature is within normal limit and behavior Assessment of APPEARANCE and behavior begins while nurse the! Exam: vitals: T: [ x ] -year-old well-developed, well-nourished Hispanic female in no distress! Documentation to just the necessities of the documentation of general APPEARANCE: the patient the! Abdominal shape, APPEARANCE bowel sounds x 4 tenderness stored in your browser 's settings exam Test Out 5 to! Newborn appears to be a well-nourished, well-developed female normal turgor, warm dry! Appearance Moving from history to physical EXAMINATION: general: the patient is a well-developed, well-nourished in... Is intact bilaterally caucasian woman, looking unwell, lying in bed, but. Welcome to use this website, but no content on the Internet lesions or ulcers.! Her blood pressure was 142/72, pulse is 78, respirations 20, and reactive to light and accommodation key. No cyanosis, clubbing, or edema Moving from history to physical EXAMINATION: signs... Appearance: patient is a testing ground for clinical forms, templates, and 98.6... Below are a few quick examples of patients I have seen: 1, blood sample, blood pressure 142/72! Myles Sheehan, S.J., M.D within normal limit sclerae were anicteric conjunctivae!, unblemished and no presence of any foul odor wounds to chest yo –...
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