Adult Physical Exams(General)

Well Appearing

Gen: Awake and alert, not in distress, overall well appearing
Pulm: Normal respirations, not in distress, CTABL
Cardiac: Regular rate and rhythm
Abd: Soft, non-tender
Neuro: Alert, No obvious acute neuro deficits

Abdominal Pain(Ill-appearing)

Gen: Awake and alert, appears in pain
Pulm: Normal respirations, CTABL
Cardiac: Regular rate and rhythm
Abd: []
Neuro: Alert, No obvious acute neuro deficits

Altered Mental Status

Gen: Altered, Ill-appearing
Head: Atraumatic
Pulm: Normal respirations, CTABL
Cardiac: Regular rate and rhythm
Abd: Soft, seemingly non-tender but limited exam
Neuro: []
MSK: No apparent deformities

Cardiac Arrest

Gen: Uresponsive
Skin: Mottled
Eyes: Pupils fixed, non-responsive to light
Head: Atraumatic
Pulm: No spontaneous respirations, coarse breath sounds
Cardiac: No appreciable cardiac sounds
Abd: Mildly distended
Neuro: No neurologic activity

Chest Pain

Gen: Alert, Sick-appearing
Pulm: Normal respirations, CTABL
Cardiac: Regular rate and rhythm
Chest wall: No focal tenderness
Abd: Soft, non-tender
Neuro: Alert, No obvious acute neuro deficits
 

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