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Normal Physical Exam Findings SOAP Note

Terms in this set (7)

General
well dressed, groomed, and nourished. Does not appear acutely ill or distressed
integument
hair on head and brows well distributed. nails and skin free of lesions
HEENT
head normocephalic and atraumatic, PERRLA, conjunctiva clear, no scleral icterus, both EACs clear and TM intact without erythema, no nasal obstruction or deviation, oropharynx clear without lesions
neck
no thyromegaly, tracheal deviation, masses, or lymphadenopathy
respiratory
chest symmetric, lungs bilaterally CTA
cardiovascular
RRR without murmur, rub, or gallop. No pitting edema over tibias or ankles. Dorsalis pedis and posterior tibial pulses 2+ and symmetric bilaterally
abdomen
soft and non-distended with active bowel sounds throughout. no tenderness, palpable masses, or organomegaly noted. No CVA tenderness
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