Physical Exam
Lori L. Lindsey-Clarkston
Lakeview College of Nursing
RN 201 Health Assessment
December 5, 2010

Physical Exam

Skin:  Pink, warm, dry, no open areas, turgor good, no tenting, not dehydrated.
Head:  Scalp intact, hair distributed evenly and clean no flaking.  No lumps or abnormalities.  
Eyes:  Symmetric with normal extra ocular movements. Pupils 3mm equal, reactive to light and accommodation.  
Ears:  Normal pinna; no external abnormalities.  Normal external canals and tympanic membranes.
Nose:  Normal nares; septum midline.
Mouth:  Oral mucosa moist, pink.  Buccal mucosa pink, moist; no lesions.  Tongue midline.  Tonsils normal in size no erythema or exudates present.  No erythema noted in pharynx.  
Neck: Supple, midline trachea, no thyroid palpable.
Lymph Nodes:  No lymphadenopathy palpable.  All lymph nodes mobile and non-tender.
Lungs:  Good expansion.  No tachypnea or dyspnea.  Lungs clear to auscultation bilaterally.  No rhonchi, rales, or crackles noted.  Chest symmetrical, without deformities.  
Cardiovascular:  PMI in fourth inter-costal space and mid-sternal line. Normal S1 and S2.  No murmurs or abnormal heart sounds. Normal femoral pulses; dorsalis and pedis pulses palpable bilaterally.  
Breast:  Normal
Abdomen:  Flat and soft; no masses.  Tenderness with palpitation to mid-epigastric region.  Liver span 2 cm below right costal margin and non-tender.  Spleen and kidneys not palpable.  
Genitalia:  Deferred.
Musculoskeletal:  Normal range of motion upper and lower extremities; all joints movable and non-painful.  Spine straight.  Gait normal.  
Neurologic:  Alert and oriented x3 person, place, and time. Bilateral grips equal no cyanosis or clubbing of finger nails.  Capillary refill 2+ fingers and toes.  

References
Jarvis, C.  (2008).  Physical examination & health assessment.  St. Louis, MO: Saunders 
       Elsevier.