Physical Exam Blurbs

  Vitals reviewed and WNL

GEN: _

NEURO: Grossly intact.  AAO.  Ambulates without difficulty.

HEENT: PERRL, EOMI, MMM.

CARD: S1 S2 RRR no M/R/G. Normal perfusion.

LUNG: CTAB no W/R/R.  Normal respiratory effort with no accessory muscle use.

ABD:    Soft, nontender, nondistended.  Normoactive bowel sounds.  No hepatosplenomegaly.  No peritoneal signs, no rebound tenderness. Negative Rovsing's.  Negative psoas.

BACK:   No CVA tendernesss.  No gross deformity.

SKIN: Skin warm and dry without rash or lesions.  

EXT:  No CCE. 

{ } ANKLE:

    Swelling: {{ } mm of pitting edema} over medial ankle.

    Ecchymosis: {}No significant ecchymosis.  

    AROM: Plantarflexion {}60 degrees, Dorsiflexion {}10 degrees.

    PROM: {}Normal.

    Strength: Normal strength in {}dorsiflexion, {}plantarflexion, {}inversion, and {}eversion.  {Pain noted with { }}.

    Special tests:

    {NEG} Thompson’s squeeze

    {NEG} Anterior Drawer

    {NEG} Talar Tilt

    {NEG} Squeeze test.

    Palpation: 

    {NO }TTP notable over medial maleolus and medial tibia.  {NO} Vibratory tenderness of tibia/fibula.  {NO }TTP of Lateral Malleolus

    {}Normal Achilles tendon, {}peroneal tendons.

    {}Normal palpation at the base of the 5th metatarsal.  

    {NO }TTP of the Talus, Navicular, Cuboid. 

    Sensation and pulses {}intact in LE.  Capillary refill {}intact and brisk.

BREAST: LEFT: Normal; no masses; no nipple abnormalities; no axillary changes. RIGHT: Normal; no masses; no nipple abnormalities; no axillary changes. ({ } present as standby)

  Vitals reviewed: BP {}wnl. HR {}wnl. RR wnl.  Weight today {}stable {increased { } lbs}

  {Orthostatic vitals: Laying: BP { }/{ } HR { }; Sitting: BP { }/{ } HR { }; Standing: BP { }/{ } HR { };}

GEN: {}AAO, NAD.

NEURO: {}Grossly intact.  Ambulates without difficulty.

HEENT: {}PERRL, EOMI, MMM.

CARD: {}S1 & S2 with no murmurs, rubs, or gallops.  {}No accessory heart sounds.  {}Regular rate, regular rhythm.  {}JVD not appreciated above sternal notch (<5cm).  {}No increased JVD with abdominojugular test.  {}Carotids auscultated bilaterally with no bruits or thrills.

LUNG: {}Normal respiratory effort with no accessory muscle use.  Clear to auscultation bilaterally.  {}No wheezes.  {}No rales.  {}No rhonchi.  {}No crackles.

ABD: {}Nontender.  Nondistended.

SKIN: {}Skin warm and dry without rash or lesions.  

EXT:  {}No lower extremity edema.  Peripheral pulses intact and equal at the radial artery{ and posterior tibial artery}.

EKG: {NSR} @ { } bpm;  PR { };  QRS { }.  QT/QTc { }/{ }.  P-R-T axes { } { } { }. 

Vitals reviewed and WNL

GEN: _

PSY:  Good eye contact during exam.  Interactive.

NEURO: Grossly intact.

EYE:  Normal conjunctiva, normal lids.  PERRL, normal iris.

ENT: Moist mucous membranes.  Normal external appearance of ears, nose. TM's normal.

NECK: Normal appearance.

LYMPH: No cervical lymphadenopathy.  No extremity lymphadenopathy.

CARD: S1, S2 RRR no M/R/G.  

LUNG: CTAB no W/R/R. Normal resp effort.

ABD: Soft, NT, ND, NABS.  No HSM.

SKIN: Skin warm and dry without rash or lesions.

EXT:  No CCE. 

GU:  Normal external genitalia.

GI:  Normal anus.

DRE:  NO external hemorrhoids.  NO internal hemorrhoids.  Prostate palpable, nontender, and with with NO abnormal masses.

ELBOW:  No obvious deformity of the elbow.  

  No TTP over medial or lateral epicondyle.  

  PROM:  Flexion to 60.  Extension to 180.  

  FROM:  Flexion to 50. Extension to 180.  

  NO impairment of supination/pronation ROM.  

  NO pain with resisted flexion, extension, supination or pronation.  

  NEG Tinel's at the cubital tunnel.

WALKING:  Normal gait.

{ } HIP:  

    ROM: Flexion to 130 degrees.  Extension to 30 degrees.  ER to 60 degrees.  IR to 45 degrees.  Popliteal angle 130 degrees.

    NO pain with resisted flexion, extension, abduction, or adduction.  

    NO snapping hip.  

    Thomas test demonstrates NO iliopsoas, NO rectus femoris, and NO ITB restriction.  

    NO pain on FADIR.  NO pain on FABER.  

    NO TTP over deep palpation of iliopsoas.  

    NO TTP over piriformis.  

    One legged stand demonstrates good strength and balance.  

  Vitals reviewed and {}WNL

GEN:    { }

HEAD: {}Normocephalic.  {}Flat and open anterior and posterior fontanel.

EYES: {}Red reflex present bilaterally.

EARS: {}Symmetric ears, no pre-auricular pits or tags. 

NOSE: {}Patent nares.

THROAT: {}Normal mouth without cleft.

CHEST: {}Symmetric.  Lungs clear bilaterally.

HEART: {}Regular rate and rhythm. No murmurs clicks or gallops.

VASC: {}Femoral and brachial pulses palpable and equal.

ABD: {}Soft.  Umbilicus normal appearance.  No abdominal masses.  No organomegaly. Bowel sounds present.

GU:     {Normal male phallus, two descended testicles, no scrotal edema.}{Normal female genitalia.  No labial adhesions.}

SPINE: {}Spine straight without midline defect.

ANUS: {}Normal.

EXT:  {}No hip click or clunk. Muscle tone normal.

SKIN: {}No abnormalities.

NEURO: {}Normal tone.

ACL Tear:

Lachman - sensitivity 60%–100%, mean 84%

Anterior drawer test - sensitivity 9%–93%, mean 62%

Pivot shift test - sensitivity 27%–95%, mean 62%

  Vitals reviewed and {}WNL

GEN: {}AAO, NAD.

SKIN: {}Skin warm and dry without rash or lesions.  

HEENT: {}PEERL, EOMI, MMM.

CARD: {}Normal perfusion.

LUNG: {}Normal respiratory effort with no accessory muscle use.

ABD: {}Nontender.  Nondistended.

BACK: {}No gross deformity. { Paraspinal TTP at { }. }{ Spinous process TTP at { }. }{ Negative straight leg raise bilaterally. }{ Single legged sit-to-stand normal bilaterally. }{ Femoral stretch test negative bilaterally. }

NEURO: {}Grossly intact. { Ambulates without difficulty. }{ DTR's intact and equal bilaterally 2/4 at the patella (L2-4), and achilles (S1-2). }{ Sensation intact and equal b/l to light touch in LE. }{ Down going toes. }

EXT:  {}No CCE. { Strength 5/5 with hip flexion, extension, knee flexion and extension, and plantar and dorsiflexion of the foot bilaterally. }

GAIT: {}Intact toe, heel, tandem and casual gait.

NECK: Range of motion with normal flexion, extension, right rotation, and left rotation.  There is no palpable paraspinal muscle spasm.  There is no midline tenderness.  Upper extremity muscle strength is normal bilaterally.  Sensation is normal bilaterally.  Reflexes: normal and symmetric at biceps, triceps, brachioradialis.

NEURO: MENTAL STATUS: Pt was alert and oriented x3 with intact language, attention, concentration, recent/remote memory and fund of knowledge per patient interview. 

CRANIAL NERVES:  CN II pupils equal, round reactive to light, visual fields full to confrontation, fundi without pallor, edema or vascular changes.  CN III/IV/VI extraocular movements intact, negative palsies.   Normal pursuits and saccades CN V face symmetric to light. Corneal reflex not tested. CN VII facial muscles symmetric, negative droop or palsy.  CN VIII grossly intact to finger rub. CN IX/X palate raise symmetric. Gag reflex not tested. CN XI sternocleidomastoid and trapezius 5/5 strength bilaterally. CN XII tongue midline without fasciculation, atrophy or deviations.

MOTOR: 5/5 strength in all extremities. Normal tone and bulk. 

SENSATION: intact to light touch, proprioception, vibration, pinprick in all extremities.

CEREBELLAR: finger-to-nose,  heel-to-shin, fine finger movements and rapid alternating hand movements intact bilaterally.  Romberg absent.  Negative pronator drift.

DTRs: 2/4 throughout with down going toes bilaterally.

GAIT: intact toe, heel, tandem and casual gait. 

General exam:

General: Well-developed/well-nourished, in no acute distress 

HEENT: Normocephalic, atraumatic. Normal optic disc. No dysmorphic features. Nares patent. No oral lesions. 

Neck: Supple, no lymphadenopathy 

Resp: Clear to auscultation bilaterally, no wheezing 

CV: RRR, no murmur 

GI: Soft, nontender, nondistended, + bowel sounds, no organomegaly, no masses 

Ext: Warm and well-perfused 

Skin: No rash, no lesions

Neurologic exam:

Mental Status:

Alert, attentive, and cooperative. Oriented to person, place, and time. Normal language output and comprehension.

Cranial Nerves:

II: PERRL, visual fields intact to confrontation

III, IV, VI: EOMI intact, no nystagmus

V: facial sensation intact bilaterally, muscles of mastication with normal strength bilaterally

VII: face symmetric, no nasolabial flattening, no delay in smile excursion

VIII: hearing intact to finger rub and conversational voice, no nystagmus

IX, X: palate elevation symmetric, no hoarseness of voice

XI: 5/5 strength in trapezius and SCM bilaterally

XII: tongue protrusion is midline

Motor:

Normal bulk and tone. No tremors or dyskinesias. No pronator drift.

Shoulder Abduction: right: 5/5 left: 5/5

Shoulder Internal Rotation: right: 5/5 left: 5/5

Shoulder External Rotation: right: 5/5 left: 5/5

Biceps: right: 5/5 left: 5/5

Triceps: right: 5/5 left: 5/5

Wrist Extensors: right: 5/5 left: 5/5

Wrist Flexors: right: 5/5 left: 5/5

Finger Extensors: right: 5/5 left: 5/5

Grip: right: 5/5 left: 5/5

Interossei: right: 5/5 left: 5/5

Hip Flexors: right: 5/5 left: 5/5

Hip Extensors: right: 5/5 left: 5/5

Hip Abductors: right: 5/5 left: 5/5

Hip Adductors: right: 5/5 left: 5/5

Knee Flexors: right: 5/5 left: 5/5

Knee Extensors: right: 5/5 left: 5/5

Ankle Dorsiflexors: right: 5/5 left: 5/5

Ankle Plantarflexors: right: 5/5 left: 5/5

Coordination:

Intact finger tapping and rapid alternating movements. Intact finger-nose-finger and heel/shin testing bilaterally.

Sensory:

Light touch: intact in all extremities

Position sense: intact in all extremities

Vibration: intact in all extremities

Temperature: intact in all extremities

Pinprick: intact in all extremities

Reflexes:

Biceps: right: 2 left: 2

Triceps: right: 2 left: 2

Brachioradialis: right: 2 left: 2

Patella: right: 2 left: 2

Achilles: right: 2 left: 2

Toes: right: down left: down

Gait and Stance:

Normal based stance. Normal gait with good arm swing and normal turns. Normal tip toe and heel walking. Intact tandem walking. Romberg test negative.

  Vitals reviewed and {}WNL

GEN: {}Normal appearing infant.

HEAD: {}Slight molding, sutures {approximated}{overlapping}, flat anterior fontanel.

EYES: {}Red reflex present bilaterally.

EARS: {}Symmetric ears, no pre-auricular pits or tags. 

NOSE: {}Patent nares, no nasal flaring.

THROAT: {}Normal mouth without cleft.

CHEST: {}Symmetric.  Clavicles intact.  Lungs clear bilaterally.

HEART: {}Regular rate and rhythm. No murmurs clicks or gallops.

VASC: {}Femoral and brachial pulses palpable and equal.

ABD: {}Soft. Umbilical stump normal appearance.  No abdominal masses. No organomegaly. Bowel sounds present.

GU:    {{}Normal male phallus, two descended testicles, no scrotal edema.} {{}Normal female genitalia.  No labial adhesions.}

SPINE: {}Spine straight without midline defect.

ANUS: {}Normal, appears patent.

EXT:  {}No hip click or clunk. Muscle tone normal.

SKIN: {}No abnormalities. {With diffuse erythema toxicum prominent over face.}  {Minimally jaundiced.}

NEURO: {}Normal plantar, palmar, suck, and moro reflexes.

PELVIC: External genitalia appear normal, no inflammation of the Bartholin’s or Skene’s glands.  Vagina rugged, pink, no lesions, no discharge, good tone.  Cervix without lesions, ectropion, or discharge.  No cervical motion tenderness.  Uterus nontender, small, firm, midline, smooth and mobile.  Adnexa bilaterally nontender, no masses.  (_ present as standby)

GU: Normal penis and testes.  NO penile lesions.  NO urethral discharge.  LEFT: NO scrotal mass, NO scrotal tenderness, NO epididymis tenderness, NO hernia.  RIGHT:  NO scrotal mass, NO scrotal tenderness, NO epididymis tenderness, NO hernia.  

{ } SHOULDER:  

    No obvious deformity.  No sulcus sign.  

    ROM: Abduction ROM 0-180.  Internal rotation to T10.  External rotation to 45.

    Strength: 5/5 ER strength.  5/5 IR strength.  5/5 scaption strength.  

    ACJ: No TTP of ACJ.  NEG cross arm adduction.  

    Impingement:  NEG Neer's arm raise.  NEG Hawkin's.

    Labrum: NEG O'Brien's;

    Rotator Cuff:  NEG empty can; NEG modified subscapularis liftoff; 

    Biceps: NO TTP of biceps tendon.  NEG Speed's.  NEG Yergason's.  

    Instability: NEG anterior apprehension.  NEG inferior apprehension.

  Vitals reviewed and WNL.  Vision test reviewed.

GEN: { } 

PSY:  {}Good eye contact during exam.  Interactive.

NEURO: {}Grossly intact.

EYE:  {}Normal conjunctiva, normal lids.  PERRL, normal iris.

ENT: {}Moist mucous membranes.  Normal external appearance of ears, nose. TM's normal.

NECK: {}Normal appearance.

LYMPH: {}No cervical lymphadenopathy.  No extremity lymphadenopathy.

CARD: {}S1, S2 RRR no M/R/G.  

LUNG: {}CTAB no W/R/R. Normal resp effort.

CHEST: {}No pectus.

BACK: {}No scoliosis.

ABD: {}Soft, NT, ND, NABS.  No HSM.  {}No Abdominal hernia.

SKIN: {}Skin warm and dry without rash or lesions.

EXT:  {}No CCE.

  Vitals reviewed and {}WNL

GEN: {}NAD.

EYE:  {}Normal conjunctiva, normal lids. {No }Scleral icterus.  PERRL, normal iris.

ENT: {}Moist mucous membranes.  Normal external appearance of ears, nose. TM's normal {without erythema, }{without effusion }bilaterally.

NECK: {}Normal appearance.  {No }Tonsillar enlargement.  {No }Tonsillar exudate. 

LYMPH: {No }cervical lymphadenopathy.

CARD: {}S1, S2 RRR no M/R/G.  

LUNG: {}CTAB no W/R/R. Normal resp effort.

ABD: {}Soft, NT, ND, NABS.  No HSM.

SKIN: {}Skin warm and dry without rash or lesions.  

EXT:  {}No CCE. 

_ WRIST:  

No gross atrophy of thenar or hypothenar eminence.  

Wrist ROM flexion 90, ext 85, ulnar and radial deviation +/- 25 respectively.  

No weakness in resisted wrist flexion, extension, ulnar or radial deviation.  

Grip 5/5.  

Thenar strength in abduction, adduction, extension 5/5.  

Ring strength 5/5.  

Digit extension strength 5/5.  

NO difficulty with thenar-digit opposition.  

NEG Tinel's at carpal tunnel (NO median distribution symptoms).  

NEG Tinel's at cubital tunnel (NO ulnar distribution symptoms);  

NEG Tinel's at Guyon canal. 

NEG Phalen's (NO paresthesias in any digits)

{ } EAR:

- PINNA: well formed. 

- EXTERNAL AUDITORY CANAL: non-stenotic without cerumen impaction. 

- TYMPANIC MEMBRANE:  intact and in good position{ with the exception of a green PE tube that is present within the inferior TM.  It appears patent and remains in good position within the TM}.   

- MIDDLE EAR SPACE: appears well aerated without evidence of effusion or active infection.