FAMILY PRACTICE TEMPLATES:
Male exam, over 50: FPMX50
PHYSICAL EXAMINATION:
GENERAL:
?? BP:. P: ??. WT: ??. HT: ??. No acute distress.
SKIN:
No suspicious lesions seen on inspection and palpation.
EYES:
PERRL. EOMI. Sclerae and conjunctivae normal.
ENT:
TMs normal. Oropharynx normal.
NECK:
Supple, no masses. No palpable thyromegaly.
RESPIRATORY:
No difficulty breathing. Clear to auscultation.
CV:
No carotid bruits. RRR, no murmur, rub or gallop. Normal S1,
S2. Pulses full and symmetrical.
ABDOMEN:
Normal bowel sounds; soft, nontender. No masses, HSM.
GU:
Penis, testes, urethra without lesions. No masses or herniae.
RECTAL:
Normal tone; no masses; normal prostate for age.
MS:
Without clubbing, cyanosis, or edema. Muscle strength and tone
normal and symmetrical.
LYMPH NODES:
No adenopathy in axillae, neck or groin.
NEURO:
Normal sensation and reflexes.
Male Exam, Under 50: FPMX49
PHYSICAL EXAMINATION:
GENERAL:
?? BP:??. P: ??. WT: ??. HT: ??. No acute distress.
SKIN:
No suspicious lesions seen on inspection and palpation.
EYES:
PERRL, EOMI. Sclerae and conjunctivae normal.
ENT:
TMs normal. Oropharynx normal.
NECK:
Supple, no masses. No palpable thyromegaly.
RESPIRATORY:
No difficulty breathing. Clear to auscultation.
CV:
RRR, no murmur, rub or gallop. Normal S1, S2. Pulses full and
symmetrical.
ABDOMEN:
Normal bowel sounds; soft, nontender. No masses, no HSM.
GU:
Penis, testes, urethra without lesions. No masses or herniae.
MS:
Without clubbing, cyanosis, or edema. Muscle strength and tone
normal and symmetrical.
LYMPH NODES:
No adenopathy in axillae, neck or groin.
NEURO:
Normal sensation and reflexes.
Female Exam, Over 50: FPFX50
PHYSICAL EXAMINATION:
GENERAL:
?? BP:??. P:??. WT:??. HT: ??. No acute distress.
SKIN:
No suspicious lesions seen on inspection and palpation.
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EYES:
ENT:
NECK:
RESPIRATORY:
BREASTS:
CV:
ABDOMEN:
GU:
RECTAL:
MUSCULOSKELETAL:
LYMPH NODES:
PERRL. EOMI. Sclerae and conjunctivae normal.
TMs normal. Oropharynx normal.
Supple no masses. No palpable thyromegaly.
No difficulty breathing. Clear to auscultation.
Without skin or nipple changes. No masses palpated.
No JVD. No carotid bruits. RRR, no murmur, rub or
gallop. Normal S1, S2. Pulses full and symmetrical.
Normal bowel sounds, soft, nontender, no masses, no
HSM.
Vulva, urethra normal. Vagina, cervix appear normal.
Uterus normal size, nontender. Adnexa: No masses or
tenderness.
Normal tone; no masses.
Without clubbing, cyanosis, or edema. Joints normal, full
range of motion of upper and lower extremities.
No adenopathy in axillae, neck or groin. ??
Extended Female Exam, Under 50: FPFX49
PHYSICAL EXAMINATION:
GENERAL:
BP:??. P: ??. WT: ?? HT: ?? No acute distress.
SKIN:
No suspicious lesions seen on inspection and palpation.
EYES:
PERRL. EOMI. Sclerae and conjunctivae normal.
ENT:
TMs normal. Oropharynx normal.
NECK:
Supple, no masses. No palpable thyromegaly.
RESPIRATORY:
No difficulty breathing. Clear to auscultation.
BREASTS:
Without skin or nipple changes. No masses palpated.
CARDIOVASCULAR:
RRR, no murmur, rub or gallop. Normal S1, S2. Pulses
full and symmetrical.
ABDOMEN:
Normal bowel sounds, soft, nontender, no masses, no
HSM.
GU:
Vulva, urethra normal. Vagina, cervix appear normal.
Uterus normal size, nontender. Adnexa: No masses or
tenderness.
MUSCULOSKELETAL:
Without clubbing, cyanosis, or edema. Joints normal, full
range of motion of upper and lower extremities.
LYMPH NODES:
No adenopathy in axillae, neck or groin. ??
Brief Female Exam: FPBFX
PHYSICAL EXAMINATION:
GENERAL:
BP:??. P:??. WT: ??. HT: ??. No acute distress.
SKIN:
No suspicious lesions seen on inspection and palpation.
NECK:
Supple, no masses. No palpable thyromegaly.
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RESPIRATORY:
BREASTS:
CV:
ABDOMEN:
GU:
LYMPH NODES:
No difficulty breathing. Clear to auscultation.
Without skin or nipple changes. No masses palpated.
RRR, no murmur, rub or gallop. Normal S1, S2. Pulses full and
symmetrical.
Normal bowel sounds, soft, nontender. No masses, no HSM.
Vulva, urethra normal. Vagina, cervix appear normal. Uterus
normal size, nontender. Adnexa: No masses or tenderness.
No adenopathy in axillae, neck or groin.
Physical Exam for Infants Under 12 months of Age: FPWB
PHYSICAL EXAMINATION:
GENERAL:
Weight:??. Length:??. HC: ??. Vigorous active infant.
SKIN:
Normal to inspection and palpation.
HEAD:
Normocephalic. Anterior fontanelle soft and flat.
EYES:
Normal red light reflex. Normal conjunctivae and sclerae.
No strabismus seen.
ENT:
TMs normal. Nares normal. Oropharynx normal.
NECK:
Neck supple without masses. No thyromegaly.
CARDIOVASCULAR:
RRR, without murmur. Pulses full and symmetric.
RESPIRATORY:
No difficulty breathing. Clear to auscultation.
ABDOMEN:
Abdomen soft, good bowel sounds, no HSM, no masses.
GU:
?? (female) Normal external genitalia and urethra.
?? (male) Normal penis and urethra. Testes descended
bilaterally.
MUSCULOSKELETAL:
Muscle strength and development normal in upper
extremities and lower extremities. Without deformity, hip
click or subluxation.
LYMPH NODES:
No suspicious adenopathy in neck or groin.
NEUROLOGIC:
Intact and appropriate for age.
ATTACHMENT:
Parent-infant bond appropriate.
CPT:99391
Family Practice – Male Adolescent: FPMA
GENERAL:
SKIN:
EYES:
ENT:
NECK:
RESPIRATORY:
CARDIOVASCULAR:
ABDOMEN:
GU:
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BP:??. WT:??. HT: ??. No acute distress.
Normal to inspection and palpation.
PERRL. EOMI. Normal sclerae and conjunctivae.
TMs clear. Throat and nose normal.
Supple without masses. Normal thyroid.
No difficulty breathing. Clear to auscultation.
RRR. S1, S2 normal. No murmurs. Pulses full and
symmetrical.
Soft, without organomegaly or masses.
Normal penis, testes, and urethra. No herniae.
MUSCULOSKELETAL:
LYMPH NODES:
NEUROLOGIC:
No evidence of scoliosis. Normal posture and gait. Muscle
development normal and joint development normal in
upper and lower extremities.
No suspicious adenopathy in neck or groin.
Normal sensation and reflexes.
Family Practice – Female Adolescent FPFA
GENERAL:
SKIN:
EYES:
ENT:
NECK:
RESPIRATORY:
CARDIOVASCULAR:
ABDOMEN:
BREASTS:
GU:
MUSCULOSKELETAL:
LYMPH NODES:
NEUROLOGIC:
BP:??. WT:??. HT: ??. No acute distress.
Normal to inspection and palpation.
PERRL. EOMI. Normal sclerae and conjunctivae.
TMs clear. Throat and nose normal.
Supple, without masses. Thyroid normal.
No difficulty breathing. Clear to auscultation.
RRR. S1, S2 normal. No murmurs. Pulses full and
symmetrical.
Soft, without organomegaly or masses.
Normal to inspection and palpation.
Normal external genitalia and urethra.
No evidence of scoliosis. Normal posture and gait. Muscle
development and joint movement normal in upper and
lower extremities.
No suspicious adenopathy in neck, axillae or groin.
Normal sensation and reflexes.
Family Practice – Well Child: FPWC
GENERAL:
SKIN:
EYES:
ENT:
NECK:
RESPIRATORY:
CARDIOVASCULAR:
ABDOMEN:
GU:
MUSCULOSKELETAL:
LYMPH NODES:
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WT:. HT:. BP: ??. No acute distress.
Normal to inspection and palpation.
PERRL. EOMI. Normal sclerae and conjunctivae. No
strabismus seen.
TMs clear. Throat and nose normal.
Supple, no masses. Thyroid normal.
No difficulty breathing. Clear to auscultation
RRR. Normal S1, S2. No murmurs. Pulses full and
symmetrical throughout.
Soft, without organomegaly or masses.
??Normal prepubertal female, normal external genitalia and
urethra.
??Normal penis and urethra. Testes descended bilaterally.
No herniae.
No evidence of scoliosis. Normal posture and gait
appropriate for age. Muscle development and joint
movement normal in upper extremities and lower
extremities.
No suspicious adenopathy in neck or groin.
NEUROLOGIC:
Appropriate for age.
Newborn History and Physical Exam: FPNB
PREGNANCY HISTORY:
DELIVERY COURSE: ??
BIRTH WEIGHT: ??
APGAR: ??
NEONATAL HOSPITAL COURSE: ??
INTERVAL PROBLEMS AND CONCERNS: ??
DIET: ??
SOCIAL HISTORY: The patient lives with ?? Parents' occupations: ?? Child care
provided by: ?? Concerns about social situation:??
PHYSICAL EXAMINATION:
GENERAL:
Weight: ??. Length: ??. HC: ??. Vigorous, healthy infant.
SKIN:
Normal to inspection and palpation.
HEAD:
Normocephalic. Anterior fontanelle soft and flat.
EYES:
Normal red light reflex, conjunctivae and sclerae.
EARS:
Helices well formed. TMs normal.
NARES:
Patent without deformity.
OROPHARYNX:
Without deformity.
NECK:
Supple. No thyromegaly.
CARDIOVASCULAR:
Regular rate and rhythm without murmur.
Pulses full and symmetric.
RESPIRATORY:
No difficulty breathing. Clear to auscultation.
CHEST WALL:
Without deformity.
ABDOMEN:
Abdomen soft, good bowels sounds, no HSM, no masses.
GU:
?? (female) Normal external genitalia, normal urethra.
?? (male) Normal penis and urethra. Testes descended
bilaterally.
MUSCULOSKELETAL:
Without deformity or hip click, subluxation or dislocation.
Symmetrical strength and movement of upper and lower
extremities.
LYMPH NODES:
No lymphadenopathy in neck or groin.
NEUROLOGIC:
Intact and appropriate for age.
ATTACHMENT:
Parent-infant bond appropriate.
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