ETABLE 3-1

eTABLE 3-1

RECORDING FINDINGS OF A NORMAL PHYSICAL EXAMINATION OF HEALTHY ADULT

Heart
Rate 82, reg rate and rhythm; no lifts, heaves Apical impulse: 5th ICS at MCL; no palpable thrills; S1, S2 louder, softer in appropriate locations; no S3, S4; no murmurs, rubs, clicks Carotid, femoral, pedal, and radial pulses present; equal, 2+ bilaterally

EXAMPLE Patients Name________________________________ Age____________

General Status
Well-nourished, well-hydrated, well-developed white (woman) or (man) in NAD, appears stated age, speech clear and evenly paced; is alert and oriented 3; cooperative, calm SkinClear s lesions, warm and dry, trunk warmer than extremities, normal turgor returns quickly, no vascularity, no varicose veins

Abdomen
No pulsations visible, rounded, active bowel sounds, no bruits or CVA tenderness, no palpable masses

Liver Nails
Well-groomed, round 160-degree angle s lesions, nail beds pink, nails exible Lower border percussed at costal margin, smooth, nontender; approx 9 cm span

Spleen Hair
Thick, brown, shiny, normal (male, female) distribution Nonpalpable, nontender

Neurologic System Head

Normocephalic, sinuses nontender Cranial nerves I-XII intact Motor (drift, toe stand) intact Coord (FN, Romberg) intact 2 2 2 Reexes: See diagram 2 2 Grading Scale 2 0 No response 1+ Diminished 2 2 2+ Normal 2 3+ Increased 2 4+ Hyperactive Sensation (touch, vibration, proprioception) intact

Eyes
Visual elds intact on gross confrontation VA: Right eye 20/20 Left eye 20/20 Both eyes 20/20 s glasses EOM: Intact on all gazes s ptosis, nystagmus Pupils: PERRLA, negative cover and uncover tests

Ears
Pinna intact, in proper alignment; external canal patent; small amount of cerumen present; TMs intact; pearly gray LM, LR visible, not bulging; whisper heard at 3 ft

Musculoskeletal System
Well developed, no muscle wasting; s crepitus, nodules, swelling ROM: Full, intact, and equal bilaterally; no scoliosis Strength: Equal, strong bilaterally 5/5 Gait: Walks erect 2-foot steps, arms swinging at side s staggering

Nose
Patent bilaterally; turbinates pink, no swelling

Female Genitalia*
External genitalia: No swelling, redness, tenderness in BUS; normal hair distribution, no cysts Vagina: No lesions, discharge; bulging, pink Cervix: Os closed; pink, no lesions, erosions, nontender Uterus: Small, rm, nontender Adnexa: No enlargement; nontender Rectovaginal: Sphincter intact; conrms above ndings

Mouth
Moist and pink, soft and hard palates intact, uvula rises midline on ahh, 24 teeth present and in good repair

Throat
Tonsils surgically removed, no redness

Tongue
Moist, pink, size appropriate for mouth

Male Genitalia
Normal male hair distribution, negative inguinal hernia Penis: Urethral opening patent; no redness, swelling, discharge; no lesions, structural alterations Scrotum: Testes descended; no redness, masses, tenderness Rectal*: No lesions, redness; sphincter intact; prostate small, nontender

Neck
Supple, s masses, s bruits, lymph nodes nonpalpable and nontender Thyroid: Palpable, smooth, not enlarged ROM: Full, intact strong Trachea: Midline, nontender

Psychologic Status
Affect appropriate Orientation: Oriented 3 Mood: Pleasant, appropriate Thought content: Intelligent, coherent Memory: Remote and recent intact Signature ________________________

Breasts
Soft, nonpendulous, s venous pattern, s dimpling, puckering Nipples: s inversion, point in same direction, areola dark and symmetric, no discharge, no masses, nontender

Axilla
Hair present, shaved, no lesions, nontender

Thorax and Lungs

AP < transverse diameter, resp rate 18, reg rhythm, no in tactile fremitus, no tenderness, lungs resonant throughout, diaphragmatic excursion 4 cm bilaterally, chest expansion symmetric, lung elds clear throughout
AC>BC, Air conduction greater than bone conduction; AP, anterior-posterior; BUS, Bartholins gland, urethral meatus, Skenes duct; coord, coordination; CVA, costovertebral angle; EOM, extraocular movements; FN, nger to nose; ICS, intercostal space; LM, landmarks; LR, light reex; MCL, midclavicular line; NAD, no acute distress; PERRLA, pupils equal, round, reactive to light and accommodation; ROM, range of motion; s, without; S1, S2, S3, and S4, heart sounds; TM, tympanic membrane; VA, visual acuity. *These data would be obtained from an examination of the genitalia if the nurse has the appropriate training.

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