PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

General Appearance:
- Pale appearing adolescent female.
- Height: 5’8 and Weight: 82 pounds (BMI of 12.5- Underweight)
Vital Signs: BP- 90/50

Body Parts Technique Normal Actual Findings Analysis

used Findings
Eyes Inspection Parallel and Normal Vision Normal
evenly spaced by Snellen
symmetrical, Chart.
non-protruding,
pink palpebral
conjunctiva, and
pupils black in
color, equal in
size, round and
constricts in
response to
light.
Normal distant
visual acuity is
20/20 with or
without
corrective
lenses.
Ears Inspection Parallel Tympanic Not Normal
symmetrical, membranes pink Patient have
proportional to and mobile. pink tympanic
the size of the membranes.
head, bean
shaped, skin is
same color as
the surrounding
color, clean and
firm cartilage.
Tympanic
membrane is
pearly gray,
shiny, and
translucent, with
no bulging or
retraction. It is
slightly concave,
smooth, and
intact.
 Mouth Inspection Symmetrical, Gag reflex Not Normal
gums pinkish in intact. Patient’s teeth is
color, lips “pit-marked” and
margin is Teeth is “pit- yellowed.
symmetrical, no marked” and
lesion and yellowed.
tenderness,
without No third molars
involuntary yet.
movement.
No decayed
areas; no
missing teeth.
Neck Inspection, Symmetrical and Two “shotty” Not Normal
palpation straight, no lymph glands Patient have two
palpable lumps palpable on left “shotty” lymph
and supple, anterior cervical glands palpable
trachea is on chain. on left anterior
midline of neck, cervical chain.
and spaces are Full range of
equal on both motion in neck.
sides.
Chest Inspection, Lungs: Respiratory rate Normal
Palpation, Symmetrical of 20 breaths
Auscultation chest expansion, per minute.
clear breath
sounds. No adventitious
Normal sounds on
respiratory rate auscultation.
of 12-20 breaths
per minute, no
reports of
dyspnea.

Heart: Normal
heart rate of 60- Heart rate at 86
100 beats per beats per
minute. No minute.
murmur, rub, or
gallop (MRG). No murmurs.

Abdomen Inspection, General contour, Soft to palpation. Normal

auscultation, no discoloration
percussion, in the abdominal No masses.
palpation wall, presence of
striae, no Neither spleen
masses, no nor liver
swishing heard. palpable.
Pelvic Exam Inspection External Deferred -
(Female genitalia reveal
Genitalia) normal BUS
(Bartholins,
Urethral,
Skene's glands)
and vulva. No
lesions,
whitened
epithelium, or
erythema.
Vagina is pink,
moist, and
rugous without
lesions. No
abnormal
discharge.
Extremities Inspection Equal size on Full range of Normal
both sides of the motion in joints.
body, no
contractures, Patellar tendon
deformities and is 2+.
tenderness,
normally firm
joints move
smoothly.
Able to actively
move all
extremities.
Deep tendon
reflexes are
graded as
follows: 0 = no
response;
always
abnormal.
1+ = a slight but
definitely
present
response; may
or may not be
normal. 2+ = a
brisk response;
normal. 3+ = a
very brisk
response; may
or may not be
normal. 4+ = a
tap elicits a
repeating reflex
(clonus); always
abnormal.