This document describes a physical exam of a 56-year-old obese man presenting for an exam. The exam evaluates each body system and finds the patient to be in generally good health with the exception of bilateral knee pain that is worse on the right side. Vital signs and measurements are taken, including a blood pressure of 166/100, weight of 185 lbs, and BMI of 33.

1. PREPARED BY:
USHA RANI KANDULA,
ASSISTANT PROFESSOR,
DEPARTMENT OF ADULT HEALTH NURSING,
ARSI UNIVERSITY, ASELLA, ETHIOPIA,
EAST AFRICA.

2.  Therefore, this examination and charting entry
are more extensive than what would be
expected of a staff nurse.

3.  Keep in mind that you should use only
abbreviations on your clinical agency’s approved
list.

4.  General Survey 56-year-old obese man presents
to the clinic for a physical exam in no apparent
distress.

5.  Pt appears stated age; is well dressed and
groomed; and alert and oriented to time, place,
and person.

6.  Speech is clear, response and affect appropriate.
 Moves all extremities well, gait steady and
balanced.
 Smells of cigarettes.

7.  Height 5 ft 4 in.
 Weight 185 lb (84 kg)
 BP 166/100
 Pulse 88 beats/min
 RR 22 breaths/min
 Temp 98.5°F (36.9°C), oral
 BMI 33

8.  Integumentary Skin even in color, warm & dry,
good turgor, no suspicious lesions.
 Well healed scar in right inguinal area.

9.  Hair clean, coarse, evenly distributed. Some
graying.
 Nails pink, brisk capillary refill, no clubbing.

10.  Head & Neck Normocephalic, erect, midline.
Scalp mobile, no lesions, tenderness, or masses.
Facial features symmetrical.

11.  Thyroid gland symmetrical and not enlarged;
cervical lymph nodes not palpable or tender.

12.  Eyes Snellen = right eye 20/100, left eye 20/100,
both eyes 20/100. Color vision intact. Difficulty
noted with near vision.

13.  Visual fields normal by confrontation.
 Extraocular movements intact.

14.  PERRLA at 3 mm by direct and consensual.
 Eyes clear and bright, + blink, no lid lag or
abnormalities.

15.  Anterior chamber clear.
 Cornea & iris intact. Sclera white, conjunctiva
clear.

16.  Lacrimal glands and ducts nontender.
 + red reflex bilateral, discs flat with sharp
margins, vessels intact, retina & macula even in
color.

17.  Ears, Nose, & Throat Skin intact, no masses,
lesions, or discharge.
 Position WNL.
 External ears nontender to palpation.
 + whisper test.

18.  Weber—no lateralization.
 External canals clear without redness, swelling,
lesions, or discharge.
 Tympanic membranes intact, light reflex and
bony landmarks visible; frontal and maxillary
sinuses nontender.

19.  Nares patent, able to distinguish familiar odors,
mucosa pink, no discharge, septum intact with
no deviation.
 Mouth Lips, oral mucosa, gingivae pink with no
lesions.

20.  All teeth present and in good repair.
 Pharynx pink, tonsils absent, palate intact.
 Symmetrical rise of the uvula, + gag and swallow
reflex.

21.  Tongue smooth, pink, symmetrical, mobile,
without lesions, taste intact (correctly identified
sweet, salty, and sour).

22.  Respiratory Respirations 22 breaths/min and
unlabored.
 Trachea midline, AP < transverse chest diameter.

23.  Chest expansion symmetrical.
 No tenderness, scars, masses, or lesions.
 Diaphragmatic excursion 5 cm. Lungs clear to
auscultation.

24.  Cardiovascular PMI @ MCL at 5th ICS, P 85,
regular, no murmurs, gallops, or thrills present;
pulses +2, no bruits or thrills, no varicosities;
jugular venous pulsation 2 cm at 45°.
 Carotids without bruits.

25.  Breasts Symmetrical.
 No masses, lymphadenopathy, or discharge.

26.  Abdomen Abdomen soft, rounded, no masses or
pulsations.
 Surgical scar R inguinal area. + bowel sounds, +
tympany throughout.

27.  Musculoskeletal Normal spinal curvature. Joints
and muscles symmetrical, no deformity. +
Bilateral knee pain (right more than left).

28.  Full ROM in upper and lower extremities, + 5
muscle strength, moderate crepitus
 right knee.

29.  Neurological Awake, alert, and oriented to time,
place, and person.
 CN I–XII intact.

30.  Gait steady and coordinated; negative Romberg;
unable to do deep knee bends due to pain.
 Point-point localization, superficial and deep
sensation intact, + 2 deep tendon reflexes.

31.  Genitourinary Circumcised male; penis
nontender, no masses, urethral meatus midline,
no discharge;

32.  testicles descended bilaterally, nontender,
inguinal and femoral canals free of masses,
prostate small, smooth, mobile, nontender.
 Rectal wall smooth, no masses, stool
 hemoccult negative.