ࡱ> ;=:` bjbj 4& T4444P$L %g%i%i%i%i%i%i%$'h)%ccc%%cg%cg%:$,#%t P2b4I$ [% %0%$R* *#%*#%8"%% %ccccL L L DL L L $ COMPLETE PHYSICAL EXAM ABBREVIATIONS: Vital Signs: T, HR, RR, BP, SPO2 SYSTEM GEN: No acute distress, alert, awake, and oriented times 4 to name, place, time, purpose, Well developed well nourished HEENT: NCAT, MMM, EOMI, PERRLA, b/l TM intact & reactive to light, b/l sclera anicteric, conjunctival injection Normocephalic atraumatic, mucous membranes moist, extraocular muscles intact, pupils equally round and reactive to light and accommodation bilaterally, bilateral tympanic membrane intact and reactive to light, bilateral sclera anicteric, no conjunctival injection NECK: Supple, JVD, LAD, carotid bruit, thyromegally Supple, no jugular venous distention, no lymphadenopathy, no carotid bruit CV: RRR, S1S2nl, m/r/g, PMI non displaced/non sustained, HJR, CR <2secs Regular rate and rhythm, S1 and S2 are normal, no murmurs/rubs/or gallops, point of maximal intensity non displaced and non sustained, no Hepatojugular Reflux, capillary refill less than 2 seconds LUNGS: CTAB, r/r/w, egophany, tactile fremitus, nl percussion Clear to auscultation bilaterally, no rales/rhonchi/wheezes, no egophany, no tactice fremitus, normal percussion ABD: Obese, no pulsatile masses, +BS nl x4, high pitched or tinkling sounds, resonant to percussion, Soft, ND/NT, rebound/guarding, CVA tenderness, HSM Obese, no pulsatile masses, normal bowel sounds normal in all four quadrants, no high pitched or tinkling sounds, resonant to percussion, Soft, non-distended/non-tender, no rebound or guarding, no costovertebral angle tenderness, no hepatosplenomegaly EXT: c/c/e No cyanosis/clubbing/or edema NEURO: CN II-XII intact, no focal deficit Cranial Nerve II through XII intact, no focal deficity PSYCH: nl affect, hallucinations, nl speech, dysarthria Normal affect, no hallucinations, normal speech, no dysarthria SKIN Intact, rashes, lesions, errythema Intact, no rashes, no lesions, no errythema GU: Male: rashes, penile discharge, penile shaft s masses or lesions, inguinal hernia, inguinal LAD, b/l testicles nl in consistency s hydrocele or varicocele, hypospadias/epispadias Male: no rashes, no penile discharge, penile shaft without masses or lesions, no inguinal hernia, no inguinal lymphadenopathy, bilateral testicles normal in consistency without hydrocele or varicocele, no hypospadias or epispadias Pelvic: rashes, nl bartholin gland, vaginal mucosa nl consistency s atrophy or discharge, cervical os s discharge Bimanual: CMT VB discharge masses No rashes, normal bartholin gland, vaginal mucosa of normal consistency without atrophy or discharge, cervical os without discharge Bimanual: No cervical motion tenderness, no vaginal bleeding, no discharge, no masses RECTAL BRBPR, melena, masses, nl sphincter tone, ext/int hemorrhoids, prostate walnut size s nodularity or hypertrophy, prostate tenderness No bright red blood per rectum, no melena, no masses,normal sphincter tone, no external or internal hemorrhoids, prostate walnut size without nodularity or hypertrophy, no prostate tenderness LYMPH: LAD No lymphadenopathy Mmsk: nl ROM, joint swelling or errythema Normal range of motion, no joint swelling or errythema %&4GHOPUZ_G M   ) * i j  & ' < ? x y '(<=BJ۸۸۸ۤۓۓۓۅۓۓۓۓۓۓۤhBXCJOJQJ^JaJ hhCJOJQJ^JaJ&hh5CJOJQJ\^JaJ hhKLCJOJQJ^JaJ#hhd]CJOJQJ\^JaJ hhd]CJOJQJ^JaJ&hhd]5CJOJQJ\^JaJ3&4HIPQVW= > G H N $h`ha$gdd]$ & F h^`a$gdd]$ & F hh^ha$gdd]$a$gdd]   ) * > ? <=CKLjk$ & F hh^ha$gdBX$ & F hh^ha$gd$ & F h^ha$gdKL$ & F hh^ha$gdd]$a$gdd]JKLjkq  ?@KLPz{EFklST[-.kl/0beпНпНННпНпННННННпННННННпННННhBXCJOJQJ^JaJ&hhd]5CJOJQJ\^JaJ hBX5CJOJQJ\^JaJ hhd]CJOJQJ^JaJ hhBXCJOJQJ^JaJhd]CJOJQJ^JaJ>kr  KLQz{klHST\$ & F hh^ha$gdBX$a$gdd]vde%&-34GHNtu$ & F hh^ha$gdBX$a$gdd]%&,34GHMtuмм&hhd]5CJOJQJ\^JaJ hBX5CJOJQJ\^JaJhBXCJOJQJ^JaJ hhd]CJOJQJ^JaJ 21h:p. 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