Physical Exam Format 1: Subheadings in ALL CAPS and flush left to the margin.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a [x]-year-old well-developed, well-nourished male/female in no acute distress.
VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula.
HEENT: Normocephalic and atraumatic. No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear.
NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness.
CHEST: Symmetric. Nontender to palpation.
LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.
HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.
BREASTS: Symmetrical. No skin or nipple retractions. No nipple discharges or masses.
ABDOMEN: Soft, flat, and benign. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass.
GENITOURINARY: [Male]. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal.
GENITOURINARY: [Female]. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal.
RECTAL: [Male]. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance.
RECTAL: [Female]. Normal sphincter tone. No masses or tenderness.
EXTREMITIES: No cyanosis, clubbing, or edema.
NEUROLOGIC: No focal sensory or motor deficits are noted. Gait is normal. Cranial nerves II through XII are intact. Deep tendon reflexes are intact.
PSYCHIATRIC: The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate mood and affect.
SKIN: Warm, dry, and well perfused. Good turgor. No lesions, nodules or rashes are noted. No onychomycosis.
LYMPHATICS: No cervical, axillary, or groin adenopathy is noted.
Physical Exam Format 2: Subheadings in ALL CAPS and transcribed in paragraph format.
PHYSICAL EXAM: GENERAL APPEARANCE: The patient is a well-developed, well-nourished female/male in no acute distress. VITAL SIGNS: Blood pressure [x] mmHg, pulse rate [x] beats per minute, respirations [x] breaths per minute, temperature [x] degrees Celsius/Fahrenheit, and O2 saturation [x]% on room air/on [x] liters nasal cannula. HEENT: Ears: There is no evidence of any external masses or lesions noted. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and moist. Septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good. NECK: Supple. Trachea is midline. There is no jugular venous distention noted. There are no carotid bruits noted. There are no palpable masses. LUNGS: Clear to auscultation bilaterally. There are no crackles, wheezes or rhonchi noted. There is no crepitus on palpation. HEART: Regular rate and rhythm, S1/S2. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation. ABDOMEN: Soft and nontender. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia. LYMPHATICS: There is no inguinal, axillary, supraclavicular or cervical adenopathy noted. SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor. MUSCULOSKELETAL: Gait is coordinated and smooth. There is no clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II through XII are grossly intact. Sensation to light touch and pain is intact bilaterally. PSYCHIATRIC: The patient is alert and oriented to person, place and time. There is no apparent mood disorder.
Physical Exam Format 3: Subheadings in Initial Caps and transcribed in paragraph format.
PHYSICAL EXAMINATION: General Appearance: This is a well-developed, well-nourished Hispanic female in no distress. Vital Signs: T: [x] degrees. P: [x] beats per minute. R: [x] breaths per minute. BP: [x] mmHg. HEENT: Normocephalic. Face: No lesions. Eyes: Conjunctiva pink. Sclera are anicteric. PERRLA. EOMs are full. Ears: The right and left ear canals are clear. Both tympanic membranes are intact. Nose: No external or internal nasal deformities. Nasal septum is midline. Mouth: The lips are within normal limits. The dentition is good. Tongue is midline with no lesions. The oral cavity is clear. Pharynx: Tonsils are normal size and clear. No exudates. Neck: Supple. No masses. No lymphadenopathy. Thyroid: No thyromegaly or masses. Chest: Clear to auscultation and percussion. Heart: Regular sinus rhythm. No gallops or murmurs. Abdomen: Soft, nontender. Normoactive bowel sounds. No organomegaly or masses. Extremities: No cyanosis, edema or deformities. Neurologic: Grossly intact. Skin: No lesions.
