AM REPORT PHYS EXAM

Physical Examination

VS:

  • 98.7F
  • HR 64/min
  • RR 18/min
  • 153/111mmHg
  • 100% on RA

 Constitutional:  Appearance: Normal appearance.

HENT: Extraocular movements intact. Conjunctivae normal.
   Pupils: Pupils are equal, round, and reactive to light. Neck: Normal range of motion.

   Cardio: Rate and Rhythm: Normal rate and regular rhythm.
   Pulses: Normal pulses.
   Heart sounds: Normal heart sounds.
Pulmonary: Normal breath sounds.

Abdominal:
   General: Bowel sounds are normal.
   Palpations: Abdomen is soft.
   Tenderness: There is no abdominal tenderness.
   Comments: Mobile semi-rigid/deformable mass in middle UQ of abdomen 

   Skin: General: Skin is warm and dry. Well healed surgical scar R knee
   Findings: Bruising present.
   Neurological:General: No focal deficit present.
   Mental Status: He is alert and oriented to person, place, and time.
   Sensory: Sensation is intact.
   Motor: Motor function is intact.
   Deep Tendon Reflexes: Reflexes are normal and symmetric.
Psychiatric:    
   Mood and Affect: Mood normal.

%d bloggers like this: