Physical Exam Clinical Note
S:
CC:
HPI:
Pqatient is a __ yo m/f c/o __________
The _ is located _, onset _ weeks/days ago, duration _ days, described as _, aggrevated by _, relieved by
_, with a severity of _/10. Patient has tried _, with little relief of S/S
PastMHx: Exam dates/findings, Chronic illness dates/signs/Tx, Infections, Alrx, Surgery (Type, complications,
anesthesia), Injuries, Hospitalizations, Immunizations, Female – GYN, Sexual History (Partners, Sexual
practices, Past history of STI, Protection from STI, Pregnancy plans)
Medications: Drug, dose, route, use, how long, effectiveness, OTCs and herbals
FamHx
Grandparents, Parents, Siblings, Children: Health, Age/Cause of death, CVD, Neuro, Pulm, Endo,
Osteoporosis, Obesity, Cancer, Bleeding, Mental/Emotional, Seizures, Substance Abuse
SocHx
Birthplace, nationality/ethnicity, marital Status, occupation, military, gender preference, SES, living
Arrangements, habits (Diet restrictions, H2O, Nutrition, exercise, Laxative & Caffeine use,
Tobacco/ETOH/Drug use, emotional, sleep, prostheses, in-home assistance, & pets
Prevention Mammogram, PAP, DRE, colon, BSE, TSE, TB & Immunizations
Violence violence and safety
ROS
Gen, HEENT, Chest, CV, Resp, GI, GU, MS, integ, neuro, psych/endo, hem/lymph, Immune/Alrx
O:
Phys Exam
General Pt acts/dresses appropriately, A&Ox4, appears rested, relaxed, good mood, well nutritioned, slouches
slightly, ambulates stable and regular w/o assist, has no S/S of distress.
Vitals
HR , RR, BP , T, Wt
H
Normocephalic, hair in good condition, temporal artery pulse NL, cranial, cervical, & clavicular nodes
palpable, soft, mobile, and nonremarkable. No S/S of TMJ
E
Ext eye/sclerae/Conj NL, funduscopic exam: red reflex present, retina/opticdisk/macula non-remarkable.
Vessels of the retina w/o nicking, narrowing, cotton wool spots, or flame hemorrhages. Retina intact.
E
Auditory canal patent, w/o erythema, edema, tenderness or drainage. TM normal color, non-tender, cone
of light present, and has no signs of infection. Rinne, Weber, and whisper tests normal.
N
Nostrils patent, normal color, non-tender, no drainage present. Turbinates normal color, shape, size and
without drainage. Frontan and maxillary sinuses percuss w/o tenderness.
T
lips, vestibule, teeth, tongue, and oral mucosa normal. Tonsils grade 2, carotids 2+, no JVD.
Neuro
Patient denies smelling issues, eyes PERRLA, 6-cardinal gazes intact, eyes open/close NL, and read
Rosenburg chart to line _. Jaw strength/open/close NL. No facial droop. Ambulates heel/toeHeel/toe w/o
difficulty, gait NL, swallow intact w/o difficulty. Uvula rise intact/symmetrical, voice clear, tongue thrust
past lips and symmetrical.
Post Thorax: Skin normal color/turgor/texture/temp. Chest expansion, symmetry, & AP-diameter NL. Spine straight,
non-tender on palpation/bending. Tactile fremitus w/o variation. No CVA tenderness. Lungs clear x5
lobes and centrally.
Ant Thorax: Skin normal color/turgor/texture/temp. No thrills. Lungs clear x5 lobes and centrally. Heart valve
sounds NL sittling/lying, with NL S1/S2 and no S3/S4 present. Apical pulse at 4-5th IC space.
Sternoclavicular palmated NL & non-tender. BSE EDU performed.
Abdomen: BS present x4 quad. No Aortic, renal, iliac, or femoral bruits present. Liver scratch test revealed span of
(6-12 NL), centered at midclavicular line. Skin color/turgor/texture/temp NL. Abdomen soft, round, nontender, and w/o heaves or pulsation. Palpated x4 quad: liver spleen, kidneys normal. Femoral pulses
present. Inguinal nodes NL non-palpable. 4 quads and liver percuss as NL. Performed TSE EDU.
BUE:
Skin normal color/turgor/texture/temp, without lesions, or edema. Full ROM with NL
flex/ex/abd/adduction at shoulder, elbow, wrists, and grasps bil. Sense to light touch present at exterior
arm/forearm/5th digit. Axillary nodes NL. Pulses 2+ at brachial, radial, and ulnar with good capillary
refill. DTRs NL.
BLE:
Skin normal color/turgor/texture/temp, without lesions, or edema. Full ROM with NL
flex/ex/abd/adduction at hip/knee/ankle/5thdigit bil. Sense to light touch present at exterior thigh, calf, &
plantar foot. Inguinal nodes NL bil. Pulses 2+ at popliteal, PT & DP. DTRs NL. No S/S of scoliosis or
gait disturbances.
A:
Pertinent S/S:
DDx’s:
(Vascular, Infection/Inflammatory/Auto-Immune, Neoplasm (Primary or Metastatic), Drugs, Iatrogenic,
Congenital/Developmental/Inherited, Anatomic, Trauma, Environmental Exposure/Endocrine/Metabolic)
P:
Plan
Tests needed, Tx (meds, etc), F/U