Physical Exam
General
Well appearing, well nourished in on distress
Skin
No rash or prominent lesions
Hair
Normal texture and distribution.
Nails
Normal color, no deformities.
Head
norm cephalic, atraumatic
Eyes
conjunctiva clear, EOM intact, PERRL
ears
Ear canals clear, tympanic membranes clear, ossicles normal appearance.
Sinuses
Non-tender
Nose
no external lesions, mucosa non-inflamed, septum and turbinate's normal.
Mouth
Mucous membranes moist, no mucosal lesions.
Teeth/gums
No obvious caries or periodontal disease.
Throat
No erythema, exudates or lesions.
Neck
Supple without lymphadenopathy.
Heart
RRR, no murmur.
Lungs
CTA bilaterally, no wheezes, rhonchi, rales. Breathing unlabored.
Chest wall
No swelling, ecchymosis, erythema, or deformity.
Abdomen
Soft, NT/ND, no HSM, no masses.
Back
Spine normal without deformity or tenderness. Normal ROM.
GU
External genitaila without lesions. Vaginal mucosa WNL, no discharge, cervix without lesions. No CMT. Uterus and adnexa nontender without masses.
Rectal
No external lesions. Normal sphincter tone, no masses palpable.