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Adult Chronic Exams
Dec 21, 2024
•
Mark Morgan
categories:
exam
These are exam templates.
ARTHRITIS
ASTHMA
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
DIABETES MELLITUS
HEART DISEASE AND STROKE
NECK: No deformity. Cervical spine range of motion - extension, flexion, rotation, abduction - Normal.
speech input
SHOULDERS: Symmetric/no deformity bilaterally. Shrug/Trapezius strength 5/5 bilaterally. Abduction/Deltoid strength 5/5 bilaterally. External/Internal strength 5/5 and range of motion normal.
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UPPER EXTREMITIES: Elbow flexion/extension normal. Wrist pronation/supination normal. Intrinsic muscles of hand/Finger Abduction strength 5/5 bilaterally. Finger flexion/Grasp strength 5/5 bilaterally. Wrist/MCP/PIP/DIP without deformity/synovitis bilaterally.
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LOWER EXTREMITIES: Quadriceps strength 5/5 bilaterally. No Knee/Ankle effusion bilaterally. Range of motion about Hips, Knees, and Ankles Normal. Gait Normal.
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BACK: Range of motion normal. No scoliosis. Hip flexion, Knee extension/flexion, Leg abduction/adduction, Ankle dorsiflexion/plantarflexion strength 5/5 bilaterally.
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GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Speaking in complete sentences.
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HEENT: TM clear, intact bilaterally without erythema. No nasal discharge. Oropharynx clear.
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NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. No JVD or HJR.
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CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor.
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LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds.
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GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress. Speaking in complete sentences.
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HEENT: TM clear, intact bilaterally without erythema. No nasal discharge. Oropharynx clear.
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NECK: Supple, non-tender without lymphadenopathy, masses or thyromegaly. No JVD or HJR.
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CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor.
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LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Good excursions.
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ABDOMEN: normal bowel sounds, no bruits, soft, nontender, nondistended
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EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities.
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GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
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HEENT: Conjunctiva without pallor; no scleral icterus.
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NECK: Supple, No JVD or HJR.
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CARDIAC: RRR with normal S1, S2 without murmer, gallop, or rub heard.
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LUNGS: Clear without rales, rhonchi, wheezing or diminished breath sounds. Good excursions.
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ABDOMEN: Soft, nontender without masses or hepatosplenomegaly. Bowel sounds are active.
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EXTREMITIES: Normal sensation to monofilament testing. Dorsalis pedis and posterior tibialis pulses 1+ and symmetric. Nails and skin appear adequately cared for without ulcer or lesion.
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GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress.
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HEENT: Eyes PERRL, EOMI. Fundi normal, vision is grossly intact. Teeth and gingiva in good general condition.
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NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly. No JVD or HJR.
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CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. No carotid bruits.
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LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds. Good excursions.
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ABDOMEN: Positive bowel sounds, no bruits. Soft, nondistended, nontender. No guarding or rebound. No masses.
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EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities. Strength at shoulder/elbow/wrist/hand 5/5 bilaterally. Strength at hips/knees/ankles 5/5 bilaterally.
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NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal.
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SKIN: Skin and nails normal, with no lesions.
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