General Appearance: alert, no apparent distress, appropriately interactive with examiner
Skin: no lesions, no jaundice
Head/Fontanelles: normocephalic, AF_____x_______, RR normal bilaterally
EENT: conjunctiva clear, nares patent, normal oral mucosa, ears normal placement, TM’s clear bilaterally
Neck: full range of motion
Lungs: CTA bilaterally, no adventitious breath sounds
CV: normal S1, S2, RRR without murmur normal femoral pulses
Abdomen: soft, no hepatosplenomegaly or masses
Extremities: no deformities
Hips: negative Barlow/Ortolani, > 60° abduction
Genitourinary: Male: testes descended, circ/uncirc // Female: normal external genitalia
Neurologic: moves all extremities symmetrically, normal tone, responds to clap, positive moro, grasp/suck/root/toe grasp
Physical Exam
PE – Peds Basic (Non-Infant)
Physical ExamGeneral- well-appearing developmentally-appropriate child in NAD, playing in exam room
Head: atraumatic, normocephalic,
Eyes: no icterus, no discharge, no conjunctivitis
Ears: no discharge, tympanic membranes nml bilat
Nose: no discharge, moist nasal mucosa
Throat: moist oral mucosa, no exudates, uvula midline
Neck: no lymphadenopathy, no nuchal rigidity
CV- RRR, nml S1, S2 w no murmurs
Respiratory- CTAB, no wheezing or crackles
Abdomen- Soft, NTND, no rigidity, no rebound, no guarding,
Extremities- warm, symmetric tone, nml muscle development and strength
Skin- moist; without rash or erythema
PE – Basic
Physical ExamGENERAL APPEARANCE: AxOx4, generally well-appearing ***M/F, no acute distress.
HEENT: NC, AT. MMM. EOMI, clear conjunctiva, oropharynx clear.
NECK: Supple without lymphadenopathy. No stiffness or restricted ROM.
HEART: Normal rate and regular rhythm, normal S1/S1, no m/r/g
LUNGS: CTAB, moving air well. No crackles or wheezes are heard.
ABDOMEN: Soft, nontender, nondistended with good bowel sounds heard.
BACK: No CVAT, no obvious deformity.
EXTREMITIES: Without cyanosis, clubbing or edema.
NEUROLOGICAL: Grossly nonfocal. Alert and oriented, moving all 4 extremities. CN not formally tested but appear grossly intact. Observed to ambulate with normal gait.
Skin: Warm and dry without any rash.