PHYSICAL EXAMINATION – child 16 years old
Vital signs:
BP 110/80 mmHg; P 89 /min reg; RR 21min; T 36.2 °C; Height: 165 cm; weight: 42 kg
General:
Well-developed, well-nourished, appearing stated age.
Alert and oriented to time, place, person, and situation. Recent and remote memory intact.
Good insight and cognitive function. No aphasia, dysarthria, or hoarseness.
Gait and station normal, Rhomberg negative.
Skin warm, dry, with good turgor, No abnormal pigmentation, bleeding, rash, or other lesions.
Hair normal texture and distribution. No nail changes.
Head:
Normocephalic without scalp lesions.
The sensation is intact over the face. No facial asymmetry, muscles of facial expression
intact.
Ears and nose without deformity, external tenderness, or discharge
Hearing intact bilaterally by rough testing (or whispering)
Eyes: Conjunctivae pink, sclerae white, without jaundice. No en- or exophthalmos or ptosis of
lids. External ocular movements (EOMs) are intact (or full), and there is no strabismus or
nystagmus. Pupils equal round and react to light and accommodation (PERRLA). Visual
fields are intact to confrontation.
Mouth and Throat: Lips are of normal color, without lesions. Teeth present, good dental
hygiene. Gums (or gingiva) and mucous membranes are pink without bleeding, lesions, or
inflammation. Tongue normal size and papillation, midline protrusion. Tonsils not enlarged
(or: absent).
Palate elevates symmetrically, gag intact.
Neck:
Neck supple with full range of motion (ROM). No masses or tenderness. Jugular venous
distension (JVD) is normal. Trachea midline. Thyroid not palpable (or normal size and
consistency). Carotid pulses are full and equal, without bruits.
Lymph Nodes: Occipital, pre- and postauricular, submandibular, anterior, or posterior
cervical, or supraclavicular nodes not enlarged.
Chest & back:
No abnormal curvature of the spine. Full range of motion, no muscle spasm or tenderness.
Breasts are symmetrical and normal in size; there are no dimpling, masses, tenderness, or
skin changes. No nipple deformity or discharge.
Axillary lymph nodes are not enlarged.
Lungs:
Respiratory excursions are full and symmetrical. Lungs resonant to percussion & vesicular
breath sounds throughout peripheral lung fields (an accepted abbreviation for normal lung
percussion and auscultation: “Clear to A&P”). No rales, Ronchi, wheezes, or rubs. Vocal and
tactile fremitus normal.
Cardiovascular:
Point of maximal impact (or: impulse) (PMI) 5th intercostal space in mid-clavicular line (MCL),
not visible. No abnormal heaves or lifts. No thrill. Regular rate and rhythm. (RR) 1st and 2nd
sounds normal intensity (2nd sound physiologically split). No extra sounds or murmurs.
Abdomen:
Scaphoid without scars. No abnormal tympany. Normal bowel sounds, no bruits. Superficial
& deep palpation without organomegaly or masses; no direct or rebound tenderness, rigidity,
or guarding. Liver edge soft (or: not palpable), liver span 10 cm. Spleen normal size (or: not
palpable), kidneys not palpable.
Extremities:
No asymmetry or muscle atrophy. Full range of motion (ROM) of all joints.
Normal skin temperature. No edema, or superficial varicosities.
Inguinal lymph nodes are not enlarged.
All distal pulses (or femoral, popliteal, PT, and DP pulses) are intact, full, and equal, no bruits
over the femoral artery.
Rectal:
No external lesions. Good sphincter tone. No tenderness or masses. Prostate firm, without
tenderness or nodules. No stool ( patient on FC)
Genitalia (female):
No swelling, redness, hair distribution,
No presence of cyst nor tumor and areas of tenderness.
