General

no distress uncomfortable ill-appearing toxic-appearing diaphoretic well-appearing

HEENT

normal conjunctivae normal TM bilaterally PERRL EOMI moist mucous membranes dry mucous membranes pharyngeal erythema no pharyngeal erythema clear oropharynx tonsillar exudates

Neck

supple no meningismus tender cervical LAD no cervical LAD midline trachea

Cardiac

regular rate and rhythm tachycardic bradycardic murmur present no murmur normal pulses irregular rhythm

Respiratory

normal breath sounds no respiratory distress wheezing rales rhonchi diminished breath sounds tachypnea

Abdominal

soft and nontender tender distended no rebound/guarding rebound/guarding present hyperactive bowel sounds hypoactive bowel sounds

MSK

normal ROM limited ROM no deformity deformity present tenderness no tenderness

Skin

warm and dry cool diaphoretic rash present no rash pallor jaundiced

Neuro

alert and oriented x3 GCS 15 cranial nerves intact no focal deficits focal deficit present normal strength weakness normal sensation sensation deficit

Psych

normal mood/affect anxious depressed agitated flat affect cooperative uncooperative