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Note
‘Aiwa iocude the patient
AAbways incline th vital signs
The follewsexe are example of write aps for the different ystems exaerives
labetoat General Sorveyh
joheval appearance babich i
Bernpies of General Sumy,
1 Pabent yollng and moving rest
Pabiént wtting canibortatily on examining table,
3. Patient sitting on exarnding table; apgeears to bem pal
4. Patient sitting comfortably of exaining tothe; appeery extn
ssh the emmy table
Physical Exam Findings - Descriptions
General Survey: Patient siting comicstably.
VSz Hall normal write WNL if not, wiite all of therm But
“Skin No tanh, wearmlmolat, turgor WHL
rhage of eaiidotas, VFA lence, TM
2a pink, nose: patent, 2
wien
HEENT: NC/AT, no pollorficterus, PEARLA, EOL t
Weber later ‘init » indict which coro” BEL nat
‘nonuoncier, cal mucosa pink, no phacyngval endates, no LAD or tryromvenaly
SevE: 51, 52 present.no M/RIG, no.1VD, no carat belts, PM
“Peripheral Vascular/Exremities: Mails-ra chibbingyevanaits
smities are cool ta touch, eo varicontiex
icalfgooit chest expansion, po ure of accessory muscles, CTAB Ho Ry
Pulses UE)
geen UL, #
ches Tenderneis, TV WNL no doliness to percussion:
Oyut
Wo Be LAS nese 8, 06 abort ts, salle teers, ater
a CUA vendorness (* needed, docuenent ys me gative shat forthe et t
ns, Rowing, Pook, Obturator, MrBurney’s|
3: No deformaitses, no swing, no tenelornes: of affactes Join, full ROW t
l ena kA