Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Examination:
General Appearance
Describe the patient’s overall health status based on appearance.
Use terms like well-developed, well-nourished, appears in no acute distress, etc.
Mention any abnormal findings like pallor, cyanosis, or edema.
Vital Signs
Include:
Blood pressure (BP)
Heart rate (HR)
Respiratory rate (RR)
Oxygen saturation (SpO2)
Temperature (Temp)
HEENT (Head, Eyes, Ears, Nose, Throat)
Head:
Normocephalic (normal size and shape) or any abnormalities like masses or tenderness.
Eyes:
PERLA (pupils equal, round, light reactive) or describe any deviations.
Extraocular movements (EOMs) – full range of motion or limitations.
Sclerae (whites of the eyes) – clear or any abnormal coloration.
Conjunctivae (pink tissue around the eyes) – pink or any redness/irritation.
Corneas (clear dome-shaped structures at the front of the eye) – clear or mention any abnormalities like clouding.
Lens (transparent structure behind the iris) – clear or mention any opacity (cataract).
Ears:
External auditory canals (ear canals) – clear or any discharge/inflammation.
Tympanic membranes (eardrums) – normal gray or any abnormalities.
Nose:
Normal septum (middle part of the nose) or mention any deviations.
Mucosa (lining of the nose) – pink or any congestion/discharge.
Throat:
Pharynx (back of the throat) – pink or any redness/inflammation.
Tonsils (lymph tissue at the back of the throat) – normal size or enlarged.
Uvula (small projection in the back of the throat) – midline or deviated.
Neck
Supple (able to move freely) or any stiffness/tenderness.
No lymphadenopathy (swollen lymph nodes).
Thyroid (butterfly-shaped gland in the neck) – normal size or enlarged.
Cardiovascular (CV)
Regular heart rhythm or describe any irregularities (e.g., murmur).
Normal heart sounds (S1 and S2) or mention any abnormalities.
Respiratory (Resp)
Clear to auscultation (listening with a stethoscope) or mention any abnormal breath sounds (e.g., wheezing, crackles).
Chest wall movement – symmetrical or asymmetrical.
Abdomen
Soft (palpable without discomfort) or any distention/tenderness.
Bowel sounds – present or absent.
No organomegaly (enlarged organs) or mention any palpable masses.
Musculoskeletal (MSK)
Normal range of motion in all major joints or mention any limitations.
No muscle weakness or atrophy (wasting).
Neurological (Neuro)
Alert and oriented to person, place, and time (AOx3) or mention any alterations in mental status.
Cranial nerves intact (normal function of the 12 nerves) or mention any deficits.
Motor function – normal strength and coordination or mention any abnormalities.
Sensory function – intact to light touch in all extremities or mention any deficits.
Extremities
No clubbing (widening and rounding of fingertips) or edema (swelling).
Normal pulses in all extremities or mention any absent/weak pulses.
Skin
Warm and moist or mention any abnormalities like dryness, rash, etc.
Additional Considerations:
This is a general template, and you may need to adjust it depending on the body systems most relevant to the patient’s presenting concerns.
Use standardized abbreviations commonly used in physical examination documentation.
Document your findings objectively and avoid medical jargon when appropriate to ensure clarity for other healthcare providers reviewing the note.
By following this Physical Examination Note Template, you can create a well-organized and informative record of your examination findings, contributing to a comprehensive patient record.