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Normal Physical Exam Template Format for Reference

PHYSICAL EXAMINATION:  At the time of admission, alert and looking older than stated age, chronically ill.  Temperature 98.4 degrees, heart rate 78, respiratory rate 20, and blood pressure 128/82.  Poor dentition.  Dry oral mucosa.  Head, ears, nose and throat examination, no significant findings.  Neck is supple.  No JVD.  No carotid bruits.  Lungs with scattered expiratory wheezing, crackles.  Severe shortness of breath with minimal activity.  Pulse oximetry was 95% on 3 liters.  Abdomen was soft and nontender.  Significant abnormality in the area of the right hip where prior hardware was removed.  Significant skin defect there, although it is well healed.  The patient is not weightbearing on the right lower extremity because of removal of the hardware.

PHYSICAL EXAMINATION:  The patient was alert and oriented x3.  Stable vital signs.  Afebrile with respirations 22, temperature 97.6 degrees, blood pressure 132/66, and pulse 90.  Eyes with white sclerae.  Mouth revealed no hemorrhages, very poor dentition.  Neck showed no cervical or supraclavicular lymphadenopathy.  Lungs were clear to auscultation.  Heart revealed regular rate at rest.  Abdomen showed postsurgical excisional healing wound with some exudations from the lower abdomen, status post squamous cell carcinoma which was performed at the other institution.  Extremities:  Large, open, shallow ulcer in lower extremity.  The other extremity with chronic venous stasis.  Neurological examination without significant findings.  On the skin, there are multiple ulcers with granulation tissue consistent with venous stasis ulcer on the lower extremities as well as ulcers present on the right lower extremity.

PHYSICAL EXAMINATION:   Alert and oriented x3 with dusky appearance and short of breath, tachypneic, hypoxic on room air, 88%.  Temperature in the emergency room was 103, heart rate 22, pulse ox 88% and blood pressure 90/60.  The patient had dusky skin, tachypneic, chronically ill appearing at the time of admission.  Oral mucosa is clean.  Mouth is with no pertinent findings.  Lungs showed coarse rhonchi, fine crackles throughout the lungs.  Breath sounds were diminished at the bases.  Heart showed regular rate and rhythm.  No murmurs, rubs or gallops.  Abdomen was soft, bowel sounds present.  Extremities with no cyanosis, clubbing, or edema.  Neurological examination was grossly intact.

GENERAL:  Examination at admission revealed the patient to be an alert male, in no apparent distress.
VITAL SIGNS:  Showed a blood pressure of 118/66, pulse 74, respirations 18, temperature 97.8.  Height 5 feet 5 inches and weight 172 pounds.
HEENT:  Unremarkable.
NECK:  Supple.
HEART:  Regular rate and rhythm with no murmurs.
LUNGS:  Clear.  No rales, rhonchi or wheezes.
ABDOMEN:  Slightly distended with active bowel sounds and with minimal epigastric tenderness.  No guarding, masses or rigidity.
EXTREMITIES:  Revealed no edema.
NEUROLOGICAL:  He was alert and oriented x3 with no focal, motor or sensory deficits.

GENERAL:  The patient is an elderly male lying in bed in no significant distress.
VITALS:  Blood pressure 122/68, pulse 72 beats per minute, respirations 18 breaths per minute, and temperature 98.2 degrees Fahrenheit.
HEENT:  No pallor and no icterus.  Extraocular muscles intact.  Pupils are round and reactive to light.  Normocephalic and atraumatic.
NECK:  No JVD.  No cervical lymph nodes.  Bilateral bruits heard.
LUNGS:  Vesicular breath sounds heard in both lung fields.  Decreased breath sounds heard in the right base.  No rhonchi.  No crackles.
HEART:  First and second heart sounds heard, irregularly irregular rhythm.  No S3.
ABDOMEN:  Bowel sounds heard in all four quadrants.  No hepatosplenomegaly.  No tenderness.  No free fluid noted.  No bruits noted.
NEUROLOGIC:  Alert and oriented x2.  Moving all four extremities to command.
EXTREMITIES:  No edema.  No Homans.  No cyanosis.  Pulses 2+.
LYMPH NODES:  No palpable lymphadenopathy.
SKIN:  No petechiae.  No purpura.  No hematomas.

VITAL SIGNS:  Temperature 98.4, pulse 72, respirations 18, and blood pressure 132/72.
GENERAL:  An elderly lady in no acute respiratory distress.
HEENT:  Atraumatic.
NECK:  Supple without bruits.
HEART:  Regular rate and rhythm.  No murmur.
LUNGS:  Clear.
EXTREMITIES:  Without clubbing or cyanosis.
NEUROLOGIC:  Mental Status:  Fully conscious and oriented x3.  Normal language and speech.  The patient was able to follow complex commands and name objects.  Short memory 1/3 in 5 minutes.  Cranial nerves II through XII, right fundus is not visualized.  Left fundus is sharp.  There is evidence of disconjugate eye movements.  Normal extraocular muscles.  Visual fields are full.  No facial weakness.  Tongue protrudes in the midline.  Motor exam:  Strength is 5/5 in proximal and distal muscles of upper and lower extremities.  Deep tendon reflexes are 1/4 in bilateral biceps, triceps, knees, and ankles.  Toes are downgoing bilaterally.  Sensory exam:  Normal to pinprick sensation.  Cerebellar:  Normal finger-to-nose bilaterally.  Gait normal.

GENERAL:  An elderly female, obese.
VITAL SIGNS:  Morning temperature 97.2; pulse 72, radial artery; respirations 20; and blood pressure measured at that time 144/78.
HEAD AND NECK:  The patient's temporal arteries are palpable.  We did not hear carotid bruits, and there is no jugular vein distention noted.  Some fullness in the neck is present but no definite thyromegaly.
HEART:  Regular rate.  No murmurs.
LUNGS:  Clear, although the patient’s inspiratory effort was not very strong.
ABDOMEN:  Soft and benign with bowel sounds present.  No abdominal pulsations and no tenderness.
EXTREMITIES:  Both upper extremity pulses were palpable with no evidence of any compromise.  In the lower extremities, on the right side, the femoral pulse could be palpated.  The popliteal and pedal pulses are not, but the entire extremity including foot and toes were warm and not compromised.  Motor and sensory function was preserved.  On the left side, the patient did not even have a femoral pulse palpable and more distal pulses were clearly absent.  The leg was cool from approximately knee down and blanched in the distal portion of the foot, and she was unable to move both foot and toes.  Sensation was also absent in the foot and abnormal in the calf; although, she did not have swelling in the calf or extreme tenderness.  She did not have evidence of peripheral aneurysms, varicose, or venous insufficiency.  Chronic pitting edema was noted to be present.

VITAL SIGNS:  Temperature 98.4, pulse 70, and blood pressure 114/62.
GENERAL APPEARANCE:  Old lady, in no acute respiratory distress.
HEAD AND NECK:  Atraumatic.  Supple without bruits.
HEART:  Irregular.  Irregular heart beats.  No murmur.
LUNGS:  Clear.
EXTREMITIES:  Without clubbing, cyanosis, or edema.
NEUROLOGIC:  Mental Status:  Fully conscious and oriented x3.  Normal language and speech.  Cranial nerves II through XII, sharp discs.  Pupils are equal and reactive to light.  Extraocular muscles are intact.  No facial weakness.  Tongue protrudes in the midline.  Motor Exam:  Strength is 5/5 in proximal and distal muscles of upper extremities and 4/5 in the proximal lower extremities.  The patient is able to dorsiflex her right foot.  Left foot is 5/5.  Deep tendon reflexes are 0/4 in bilateral biceps, triceps, knees, and ankles. Toes are downgoing bilaterally.  Sensory Exam:  Normal to pinprick sensation.  Cerebellar, normal finger-to-nose bilaterally.

GENERAL:  This is a (XX)-year-old lady.
VITAL SIGNS:  Blood pressure 142/76, respiratory rate is 20, temperature 96.8, and O2 saturation on 3 liters 93%.
NECK:  Revealed jugular venous distention of 45 degrees.  There are no surgical scars noted.  On palpation, there is no adenopathy.  No thyromegaly.  Carotid pulses, upstroke is normal, but rhythm appears to be irregularly irregular.  On auscultation, there are no venous hums or bruits.
CHEST:  Inspection of the chest is normal.  Percussion reveals slight dullness on both basilar regions.  On auscultation, breathing sounds are diminished at the basilar regions.
HEART:  Palpation, negative for thrills, heaves, or lifts.  On auscultation, the rhythm was irregularly irregular.  First heart sound is normal.  Second sound is split physiologically.  There is an S3 gallop present with a grade 1/6 systolic at the apical region.
ABDOMEN:  Soft.  No pulsatile mass or bruits.  No organomegaly.  Bowel sounds were normal.
EXTREMITIES:  Lower extremities, dorsalis pedis and posterior tibialis, popliteal, and femorals all present and equal bilaterally at 4+.  No edema.

GENERAL APPEARANCE:  Alert, oriented, and very pleasant gentleman in no distress at all at the time of evaluation.
VITAL SIGNS:  Blood pressure in the supine position in the right arm 120/62, temperature 97, O2 saturation 97% on 2 liters nasal cannula, and respiratory rate 18.
NECK:  Obese.  Difficult to examine, but at least on palpation there was no thyromegaly.  Carotid pulses appear to have normal upstroke.  On auscultation, there were venous hums or bruits.
LUNGS/CHEST:  Clear and normal to percussion and inspection.  Anterior chest demonstrated well-healed prior remote median sternotomy scars.  On palpation, there was no tenderness on the chest wall.  There were no heaves and no lifts.
HEART:  Rhythm was regular.  The rate was 50.  First and second sounds were normal.  There was no gallop, murmur, rubs, or clicks.
ABDOMEN:  Obese.  Quite difficult to examine because of size but grossly no organomegaly.  No tenderness.  No rebound tenderness.  Bowel sounds appeared normal, and pulsatile masses could not be excluded because of size.
EXTREMITIES:  Some skin changes are present in the lower extremities suggestive of chronic edema, now resolved.  Pulses, dorsal pedis and posterior tibialis not felt.  Popliteal is not felt.  Femoral is 2+.

GENERAL:  A well-developed, well-nourished, well-oriented, well-cooperative, very pleasant (XX)-year-old woman.  Her weight is 150 pounds which is 68 kilograms. Height is 5 feet 2 inches which is 158.49 cm.
VITAL SIGNS:  Blood pressure is 116/80 mmHg, pulse rate is 76 beats per minute, respirations are 18 breaths per minute, temperature 98.6 degrees Fahrenheit, and O2 saturation 99%.
HEENT:  Eyes, moving in all directions without anisocoria and reactive to light.  Funduscopic examination shows there is no hard exudate.  No blot hemorrhage in both fundi.  Tongue not dehydrated.
NECK:  Supple.  No JVD.  Carotid upstroke normal without bruit.
HEART:  There is no S3 gallop.  No murmurs.
LUNGS:  Clear without expiratory wheezing or without inspiratory rales.
ABDOMEN:  Distended with a fetus.  There is no tenderness.  Fetal heart sound is not audible with the stethoscope at this time.
EXTREMITIES:  No pedal edema.  Pain and touch sensation are good in both feet and peripheral pulsations are palpable, dorsalis pedis artery as well as posterior tibial artery bilaterally.