PHYSICAL EXAMINATION

Patient: [Name, age]
Date and time: [Date, time]
Examiner: [Name, credentials]
Type of exam: [Complete, or focused on the presenting problem]
Reason for exam: [New patient, pre-employment, symptom, or follow-up]

VITAL SIGNS
Blood pressure: [Reading in mmHg, arm and position, repeated after rest if high]
Heart rate: [Beats per minute, regular]
Respiratory rate: [Breaths per minute, counted]
Temperature: [Reading and route]
Oxygen saturation: [Percent on room air, or on oxygen with device and flow]
Height, weight, and BMI: [Measurements, when taken]
Pain: [Score out of 10 and site, or none]

GENERAL APPEARANCE
[Well appearing, alert, in no acute distress. Well nourished and well groomed.]

SKIN
[Warm and dry. Normal color, no pallor, jaundice, or cyanosis. No rash, lesions, or bruising.]

HEAD AND EYES
Head: [Normocephalic, atraumatic.]
Eyes: [Conjunctivae clear, sclerae anicteric. Pupils equal, round, and reactive to light. Extraocular movements full.]
Visual acuity: [Right and left eye, corrected or uncorrected, when tested]

EARS, NOSE, AND THROAT
Ears: [External ears normal. Canals clear. Tympanic membranes intact and pearly gray.]
Hearing: [Whispered voice heard in both ears, when tested]
Nose: [Mucosa pink, no discharge. Septum midline.]
Mouth and throat: [Mucous membranes moist. Dentition in good repair. Pharynx without redness or exudate. Tonsils not enlarged.]

NECK AND LYMPH NODES
Neck: [Supple, full range of motion. Trachea midline. Thyroid not enlarged, no nodules.]
Lymph nodes: [No cervical or supraclavicular lymphadenopathy.]

CARDIOVASCULAR
Heart: [Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs, or gallops.]
Pulses: [Radial and dorsalis pedis pulses 2+ and equal on both sides.]
Edema and neck veins: [No peripheral edema. No jugular venous distension.]

RESPIRATORY
Inspection: [Breathing unlabored, no accessory muscle use. Chest expands equally.]
Auscultation: [Clear to auscultation on both sides. No wheezes, crackles, or rhonchi.]
Percussion: [Resonant throughout.]

ABDOMEN
Inspection: [Flat, no scars, distension, or hernias.]
Auscultation: [Normal bowel sounds.]
Percussion: [Tympanic, no shifting dullness.]
Palpation: [Soft, non-tender. No guarding or rebound. No masses. Liver and spleen not enlarged.]
Flanks: [No costovertebral angle tenderness.]

MUSCULOSKELETAL
Joints: [Full range of motion of all major joints. No swelling, redness, deformity, or tenderness.]
Spine: [Normal curvature. No midline tenderness. Full range of motion.]

NEUROLOGICAL
Mental status: [Alert and oriented to person, place, and time.]
Cranial nerves: [II to XII intact.]
Motor: [Normal bulk and tone. Strength 5/5 in all four limbs.]
Sensation: [Intact to light touch in all four limbs.]
Reflexes: [2+ and symmetric at biceps, triceps, knees, and ankles. Plantar responses flexor.]
Coordination and gait: [Finger-to-nose normal. Gait steady. Romberg negative.]

PSYCHIATRIC
[Calm and cooperative. Mood and affect normal. Speech normal in rate and volume. Thought process logical. Insight and judgment intact.]

BREAST, GENITOURINARY, AND RECTAL, WHEN INDICATED
Consent and chaperone: [Consent given. Chaperone offered: name and role, or declined by the patient]
Breast: [Symmetric. No masses, skin changes, or nipple discharge. No axillary lymphadenopathy.]
Genitourinary: [Normal external genitalia. No lesions, discharge, or hernia.]
Rectal: [Normal sphincter tone. No masses or tenderness.]

FINDINGS AND IMPRESSION
Abnormal findings: [Each one by system: what you saw, felt, or heard, with side, site, size, and grade]
Not examined: [Systems not examined, and why]
Impression: [Normal examination, or what the findings suggest]
Next steps: [Tests, treatment, referral, or follow-up the findings lead to]

Signed: [Examiner name, credentials, date and time]