example how to document physical exam findings

HEENT

• head: atraumatic,normocephalic
• eyes : EOMI,PERRLA, normal eye fundus
• nose : no nasal congestion
• throat : no tonsilar eythema
• mouth : moist mucous membranes,good dentition, no lesions

NEck:

• supple , no JVD ,normal thyroid,no cervical LAD

Nervous system

• mental status: alert and orientedx3 ,good concentration 
• CN II-XII grossly intact
• Motor: strength 5/5 in all muscle groups
• DTR:2+intact and symmetric ,babisnki -ve
• sensation : intact to sharp and dull
• cerebellum: -ve romberg sign,intact finger to nose ,normal heel to shin and no dysdiadokinesis

chest/lung:

• clear to auscultation bilaterally
• no rales,ronchi ,wheezing or rubs
• no tenderness to papation
• tactile fremitus within normal limit

HEart:

RRR,S1S2 WNL,no RMG(rubs,mumrmur,gallops), PMI not displaced,no JVD,clubbing edema.

abdomen:

soft,nontender,nondistended,BS positive,no hepatosplenomegaly

extremities

• no clubbing cyanosis or edema .Carotid,radial,DP,PT pulse NL & equal B/L. no carotid bruits 

Mental status exam:

• pt speaks slowly
• no hostile behavior toward interviewer
• blunt affect with poor eye contact
• inattentive to interviewer
• 3/3 registration,3/3 recall at 3minutes
• distant memories are intact/impair
• oriented to person,date and place
• completed 3 step commandright handed
• 1/5 on serial 7s
• poor judgement