Davao medical school foundation, inc.

– College of medicine
Department of Internal Medicine

Physical Examination Findings

General Survey Vital Signs Skin HEENT Neck Lungs

Pupils are equally round and

Awake, cooperative,
BP 145/95 Negative for rash nor reactive to light and Neck supple Equal chest
coherent
HR 126 bpm other lesions accommodation Trachea midline expansion
Oriented to time,
RR 22 cpm, not Warm to touch Anicteric sclera No palpable nodes Resonant
place and person
labored Good skin turgor and No nasal drainage No vein distention Crackles Right mid
Not in respiratory
T 41.2 C mobility Dry oral mucosa No neck mass to base, Left base
distress
Tonsils not enlarged, no exudates

Heart Abdomen Genitalia/Rectum Extremities Neuro

No sensory or motor deficit
PMI at 5th ICS, 7.5 cm
Normoactive bowel DRE reveals good sphincter ton, CNs II-XII intact
from the midline No clubbing, cyanosis,
sounds Soft, nontender, no masses, no tenderness, Negative Babinski
Tachycardic, regularly nor edema
nondistended empty rectal vault, and no DTRs = 2+
regular rhythm, Pulses 2+ bilateral in all
No guarding, no rebound blood on the examining finger Muscle strength = 5/5 all
distinct S1 and S2, no extremities
tenderness Prostate measured 2 x 2 cm, extremities
extra heart sounds, Intact ROM
No bruits, no masses without nodules, no asymmetry (-) Romberg
no murmur
(-) Pronator drift

Height 5’5’’, Weight 78 kilograms

Prepared by: M. platero, rn, md, fpcp 1