Short and sweet, and all you really will likely need for a PE written right in the chart:
General: AAO x 3, NAD, pleasant
Vitals: T 100.2 noted, o/w WNL
HEENT: NCAT, EOMI, PERRLA, MMM, no lymphadenopathy, no thyromegaly, TM intact
CV: RRR, S1 S2 audible, no S3, S4, no g/r/m, PMI not displaced, no JVD, no carotid bruits, CR < 2 sec
Lungs: CTA bilaterally, no r/r/w, no egophany, tactile fremitus WNL
Abd: Soft, NT, ND, tympanic x 4, BS x 4, no organomegaly
Back: No step-offs, midline spine, no CVA tenderness
Ext: no cyanosis, no edema, + 2 peripheral pulses b/l
Neuro: CN 2-12 intact with L sensorineural hearing loss, 5/5 strength x 4 b/l w/ good tone, sensation to LT intact symmetrically and b/l,
RAM intact, finger-to-nose intact, proprioception intact, negative Romberg's, steady gait
The whole nine yards, as expected by one attending:
General: well-nourished African-American man, alert and oriented to questioning; pleasant demeanor; no acute distress.
HEENT: patient was normocephalic and atraumatic; pupils were equal, round and reactive to light and accommodation; extra-ocular movements intact; no visual field loss; oral mucosa moist without any visible lesions; no submandibular, occipital, supraclavicular or cervical lymphadenopathy; neck was supple, thyroid not obviously enlarged, trachea was midline; external ears appeared normal.
CV: No JVD; +2 DP pulses bilaterally, +2 radial pulses bilaterally; regular rate and normal rhythm, normal S1 and S2, no murmurs, rubs or gallops; no carotid bruits.
Respiratory: symmetric expansion on inspection; tactile fremitus was present equally bilaterally on palpation; lungs were resonant on percussion; vesicular breath sounds bilaterally, no wheezes, rales or rhonchi noted.
Abdomen: no visible lesions or abnormalities on inspection; normoactive bowel sounds in all four quadrants; some epigastric tenderness on deep palpation; non-distended; no hepatosplenomegaly noted, but it was difficult to palpate; tympanic in all four quadrants.
Extremities: no cyanosis, clubbing or edema; sensation present in all four extremities with no focal deficits.
Musculoskeletal: good muscle tone in upper and lower extremities bilaterally
Neurological: patient was alert and oriented to questioning; cranial nerves 2-12 intact grossly; motor strength was 5/5 in bilateral upper and lower extremities; downgoing toes bilaterally; no dysequilibrium noted in gait; DTRs: 1+ biceps/triceps/brachioradialis/Achilles/patellar tendon bilaterally. Recruitment utilized for lower extremity DTRs. No dysdiadochokinesia noted. Speech was fluent and appropriate. Affect was congruent.
Rectal: weakly positive guaiac reported by the ED physician.
