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
- Last updated January 16, 2023