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ADULT EXAM

- GENERAL: Alert, calm, conversant in NAD
- HEAD: Normocephalic, atraumatic
- EYES: Clear without discharge. No photophobia
- ENT: No stridor, drooling, trismus or dysphonia. Moist
- NECK: Trachea midline. Supple
- LUNGS: Unlabored respirations.  No splinting. No rales.  No wheezing.
- HEART: Normal rate. Regular. Normal heart sounds.
- CHEST: No tenderness
- ABDOMEN: Soft, non-tender. No guarding. No rebound
- GENITOURINARY: No CVAT
- SPINE: No deformity noted.
- EXTREMITIES: No edema. No tenderness. Homan’s negative. Symmetric pulses
- NEUROLOGIC: Normal speech. No focal weakness. Alert and oriented.
- PSYCHIATRIC: Normal mood. No SI
- SKIN: No erythema.

from emresource.org

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