Module 2 Physical Exam Essential Scribe

Alert (Constitutional)

Patient is awake and responsive.

No acute distress (Constitutional)

Patient is not showing signs of pain or discomfort.

Well-developed, well-nourished (Constitutional)

Patient appears to have appropriate growth and nutritional status.

Warm (Skin)

Skin feels warm to the touch, indicating normal perfusion.

Dry (Skin)

Skin is not moist or clammy.

Pink (Skin)

Skin has a healthy color.

Intact (Skin)

Skin is not broken or damaged.

No signs of infection (Skin)

No visible signs of skin infection.

No rashes (Skin)

No abnormal skin eruptions present.

No signs of trauma (Skin)

No bruises, cuts, or other injuries observed.

Normocephalic (Head/Neck)

Head is of normal shape and size.

Atraumatic (Head/Neck)

No signs of trauma to the head or face.

No head tenderness (Head/Neck)

No pain upon palpation of the head.

Supple (Head/Neck)

Neck moves easily without stiffness.

Trachea midline (Head/Neck)

Trachea is centered and not deviated.

No JVD (Head/Neck)

No jugular venous distention, suggesting normal central venous pressure.

No cervical lymphadenopathy (Head/Neck)

No swelling of the lymph nodes in the neck.

No carotid bruit (Head/Neck)

No abnormal sounds over the carotid arteries.

No neck tenderness (Head/Neck)

No pain on palpation of the neck.

No deformity (Head/Neck)

Anatomy appears normal and undistorted.

PERRLA (Eyes)

Pupils Equal, Round, and Reactive to Light and Accommodation.

EOMI (Eyes)

Extraocular Movements Intact, eyes move normally in all directions.

Normal conjunctiva (Eyes)

Inner lining of the eyelid appears healthy.

Anicteric sclera (Eyes)

Whites of the eyes are not yellow.

TMs clear (ENMT)

Tympanic membranes (eardrums) are not inflamed or blocked.

Normal nares (ENMT)

Nasal passages appear clear and unobstructed.

Moist mucous membranes (ENMT)

Oral and nasal mucosa are properly hydrated.

Normal oropharynx (ENMT)

Throat appears healthy without abnormalities.

No lymphadenopathy (Lymphatic)

No swollen lymph nodes detected.

Regular rate (Cardiovascular)

Heart rate is within normal limits.

Regular rhythm (Cardiovascular)

Heartbeat follows a consistent pattern.

No edema (Cardiovascular)

No swelling from fluid accumulation.

Good capillary refill (Cardiovascular)

Blood returns to distal tissues quickly after pressure is released.

Strong, equal distal pulses (Cardiovascular)

Pulses are equal and strong in peripheral limbs.

Normal heart sounds (Cardiovascular)

No murmurs, rubs, or gallops detected.

Lungs CTA (Respiratory/Chest Wall)

Clear to auscultation, no abnormal breath sounds.

Equal breath sounds (Respiratory/Chest Wall)

Breath sounds are the same on both sides.

Non-labored respirations (Respiratory/Chest Wall)

Patient is breathing easily without effort.

No chest wall tenderness (Respiratory/Chest Wall)

No pain with palpation of the chest.

No chest wall deformity (Respiratory/Chest Wall)

Chest shape is normal with no abnormalities.

Normal breast exam (Respiratory/Chest Wall)

No lumps or other concerning findings in the breasts.

Soft (Gastrointestinal)

Abdomen is soft to touch.

Nontender (Gastrointestinal)

No pain when the area is touched.

Nondistended (Gastrointestinal)

Abdomen is not bloated or enlarged.

Normal bowel sounds (Gastrointestinal)

Typical gurgling heard upon auscultation.

No palpable masses (Gastrointestinal)

No abnormal lumps felt.

Normal rectal exam (Gastrointestinal)

No abnormalities detected during rectal examination.

Normal external female genitalia (Genitourinary)

Female genital anatomy appears normal.

Normal bimanual exam (Genitourinary)

Pelvic exam shows no abnormalities.

Normal speculum exam (Genitourinary)

Cervix and vaginal walls appear healthy.

Normal external male genitalia (Genitourinary)

Male genital anatomy appears normal.

Nontender bones/muscles (Musculoskeletal)

No pain when bones or muscles are palpated.

Full range of motion (extremities) (Musculoskeletal)

Extremities can move fully and freely.

Normal muscle strength (Musculoskeletal)

Muscle strength is within expected limits.

Distal neurovascular intact (Musculoskeletal)

Blood flow and nerve function at extremities are normal.

No bony deformity (Musculoskeletal)

Bones appear normally shaped and aligned.

Nontender back (Musculoskeletal)

No pain on palpation of the back.

No back deformity (Musculoskeletal)

Back appears straight and normal.

Full range of motion (back) (Musculoskeletal)

Back can move in all directions without restriction.

A/O x4 (Neurological)

Alert and oriented to person, place, time, and situation.

Normal speech (Neurological)

Speech is coherent and appropriate.

No focal neuro deficits (Neurological)

No localized neurological issues.

Normal sensation (Neurological)

Normal ability to feel touch and other stimuli.

Normal deep tendon reflexes (Neurological)

Reflexes are present and within normal limits.

Cranial nerves II - XII intact (Neurological)

Cranial nerves function normally.

Normal gait (Neurological)

Walking pattern is normal.

Normal finger-to-nose, heel-to-shin (Neurological)

Coordination tests are normal.

Negative Romberg’s (Neurological)

No balance issues with eyes closed.

No meningismus (Neurological)

No signs of meningitis (e.g., neck stiffness).

Cooperative behavior (Psychiatric)

Patient is engaged and responsive.

Appropriate mood and affect (Psychiatric)

Emotional state matches the situation.

Normal judgement (Psychiatric)

Patient displays logical thinking.

Non-suicidal (Psychiatric)

No suicidal thoughts or behavior noted.