PHYSICAL EXAM

PATIENT NAME:

VISIT DATE:

VITALS

BP:

P:

TEMP:

WT:

GENERAL

Level of consciousnes is:

Normal

Yes

No

Orientation is:

Normal

Yes

No

Level of distress is:

Normal

Yes

No

Patient's nourishment is:

Normal

Yes

No

Overall appearance is:

Normal

Yes

No

Patient is on crutches or braces:

Normal

Yes

No

Patient is in a wheelchair:

Normal

Yes

No

Uses hearing aid(s):

Yes

No

Comments:

HEAD

Head Exam is:

Normal

Yes

No

Head is:

Atraumatic

Yes

No

Head is:

Normocephalic

Yes

No

Hair Exam is:

Normal

Yes

No

Hair Exam Shows:

Alopecia Areata

Yes

No

Hair Exam Shows:

Alopecia Totalis

Yes

No

Hair Exam Shows:

Alopecia Universalis

Yes

No

Comments:

EYES

Right sclera is:

Normal

Yes

No

Left sclera is:

Normal

Yes

No

Right sclera:

Icterus

Yes

No

Left sclera:

Icterus

Yes

No

Right external lid is:

Normal

Yes

No

Left external lid is:

Normal

Yes

No

Puffiness under Eyes:

Present

Yes

No

Right cornea is:

Normal

Yes

No

Left cornea is:

Normal

Yes

No

Right conjunctiva is:

Normal

Yes

No

Left conjunctiva is:

Normal

Yes

No

Right conjunctiva is:

Injected

Yes

No

Left conjunctiva is:

Injected

Yes

No

Right pupil is:

Normal

Yes

No

Left pupil is:

Normal

Yes

No

Pupils Are:

Equal Size

Yes

No

Round

Yes

No

Anisocoria

Yes

No

React to Light

Yes

No

Direct

Yes

No

Consensual

Yes

No

Comments:

EARS

Right ear canal is:

Normal

Yes

No

Left ear canal is:

Normal

Yes

No

Right ear inspection is:

Normal

Yes

No

Left ear inspection is:

Normal

Yes

No

Right ear palpation is:

Normal

Yes

No

Right tympanic membrane is:

Normal

Yes

No

Left tympanic membrane is:

Normal

Yes

No

Right tympanic membrane is:

Injected

Yes

No

Left tympanic membrane is:

Injected

Yes

No

Cerumen is:

Present

Yes

No

Right ear hearing is:

Normal

Yes

No

Left ear hearing is:

Normal

Yes

No

Comments:

SINUS / NASAL

Turbinate Swelling:

Swollen Inferior Turb

Yes

No

Right Turbinate

Yes

No

Left Turbinate

Yes

No

Septum exam is:

Normal

Yes

No

Septum is:

Deviated right

Yes

No

LSeptum is:

Deviated left

Yes

No

External nose exam is:

Normal

Yes

No

Right nare exam is:

Normal, Patent

Yes

No

Left nare is:

Normal, Patent

Yes

No

Nasal Mucosa exam is:

Normal

Yes

No

Nasal Mucosa is:

Dry

Yes

No

Nasal Mucosa has:

Soft Crusting

Yes

No

Nasal Mucosa has:

Dry Crusting

Yes

No

Nasal Mucosa has:

Excoriation and blood

Yes

No

Left sinus exam is:

Normal

Yes

No

Right Sinus Exam is:

Normal

Yes

No

Comments:

MOUTH/THROAT

Lips exam is:

Normal

Yes

No

Lips Are:

Dry

Yes

No

Lips exam Shows:

Angular Cheilitis

Yes

No

Lips exam Shows:

Candida Cheilitis

Yes

No

Buccal mucosa exam is:

Normal

Yes

No

Buccal mucosa is:

Moist

Yes

No

Buccal mucosa is:

Dry

Yes

No

Buccal mucosa has:

Lesions, canker sores

Yes

No

Teeth/gums exam is:

Normal

Yes

No

Teeth are in:

Good Repair

Yes

No

Teeth are in:

Poor Repair

Yes

No

Gums are:

Receding

Yes

No

Tongue exam is:

Normal

Yes

No

Tongue is:

Swollen, has teeth marks

Yes

No

Tongue is:

Coated White

Yes

No

Tongue is:

Geographic

Yes

No

Tongue shows:

Thrush (Candidiasis)

Yes

No

Comments:

THROAT

Palate & uvula exam is:

Normal

Yes

No

Uvula is:

Deviated to the right

Yes

No

Uvula is:

Deviated to the left

Yes

No

Tonsils exam is:

Normal

Yes

No

Tonsils exam shows:

Enlarged Tonsils

Yes

No

Tonsils exam shows:

Kissing Tonsils

Yes

No

Oropharynx exam reveals:

Erythema

Yes

No

Postnasal Drip

Yes

No

Severity:

Mild

Yes

No

Moderate

Yes

No

Severe

Yes

No

Cobble Stones

Yes

No

Comments:

NECK/LYMPH/THYROID

Neck is:

Normal

Yes

No

Supple

Yes

No

Inspection is:

Normal

Yes

No

Palpation is:

Normal

Yes

No

Lymph nodes are:

Normal

Yes

No

Thyroid gland is:

Normal

Yes

No

Range of motion:

Normal

Yes

No

Comments:

HEART

Distal pulses are:

Normal

Yes

No

Palpation is:

Normal

Yes

No

Bruits are absent:

Normal

Yes

No

Auscultation is:

Normal

Yes

No

S1:

Normal

Yes

No

S2:

Normal

Yes

No

Rate and Rhythm Are:

Regular

Yes

No

Heart murmurs:

Present

Yes

No

Comments on Grade: II/VI III/VI IV/VI Pansystolic

Rubs:

Present

Yes

No

Gallops:

Present

Yes

No

S3:

Present

Yes

No

S4:

Present

Yes

No

Carotid exam is:

Normal

Yes

No

Carotid Bruit is:

Present (Right)

Yes

No

Carotid Bruit is:

Present (Left)

Yes

No

JVP exam is:

Normal

Yes

No

Comments:

LUNG

Inspection is:

Normal

Yes

No

Respirations are:

Normal

Yes

No

Lung sounds are:

Normal

Yes

No

Palpation is:

Normal

Yes

No

Percussion of lung is:

Normal

Yes

No

Ausculation is:

Normal

Yes

No

Lungs Are:

Clear

Yes

No

Lungs Have:

Wheezing

Yes

No

Lungs Have:

Rales

Yes

No

Lungs Have:

Rhonchi

Yes

No

Cough is absent:

Normal

Yes

No

Comments:

ABDOMEN

Distended :

Normal

Yes

No

Bowel Sounds Present :

Normal

Yes

No

Tender on Palpation:

Normal

Yes

No

Organomegaly:

Normal

Yes

No

Comments:

MUSCULOSKELETAL

Neck Pain:

Normal

Yes

No

Back Pain:

Normal

Yes

No

Shoulder Pain:

Normal

Yes

No

Knee Pain:

Normal

Yes

No

Comments:

SKIN

Atopic Dermatitis Lesions:

Present

Yes

No

Infected

Yes

No

Dermatophytosis Skin lesions:

Tinea Corporis

Yes

No

Tinea Versicolor

Yes

No

Skin Candidiasis

Yes

No

Tinea unguium

Yes

No

Urticaria Skin lesions:

Present

Yes

No

Dermatographism:

Present

Yes

No

Morgellons Skin Lesions:

Present

Yes

No

Comments:

SUPERFICIAL AND DEEP TENDON REFLEX

Reflexes are:

Normal

Yes

No

Deep Reflexes:

Normal

Yes

No

Touch:

Normal

Yes

No

Vibiratory:

Normal

Yes

No

NEUROLOGICAL

MENTAL STATUS:

Normal

Yes

No

Alert and oriented X 3:

Normal

Yes

No

Grossly normal intellect:

Normal

Yes

No

Cranial Nerves:

Normal

Yes

No

SENSORY FUNCTION

Coordination intact:

Normal

Yes

No

Skills normal:

Normal

Yes

No

Balance and gait intact:

Normal

Yes

No

No sensory loss:

Normal

Yes

No

Next Step

EVALUATION and TESTING

Reported Medications on:

Skin Testing and Treatment:

BLOOD TESTS ORDERED

Physician follow-up with results and recommendations in approximately two weeks

IN LABS:

TREATMENT PLAN and MEDICAL DECISION MAKING

IMPRESSIONS:

PLAN:

Diagnosis Codes

ICD 10 Codes:

Back