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- GENERAL: Alert, calm, happy in NAD

- HEAD: Normocephalic, atraumatic

- EYES: Clear without discharge. No photophobia

- ENT: No stridor, drooling, trismus or dysphonia. Moist

- NECK: Trachea midline. Supple

- LUNGS: Unlabored respirations. No splinting. Clear. No splinting. No rales or wheezing.

- HEART: Normal rate. Regular. Normal heart sounds.

- CHEST: No tenderness

- ABDOMEN: Soft, non-tender. No guarding. No rebound


- EXTREMITIES: No edema or tenderness. Symmetric pulses

- NEURO: Normal speech. No focal weakness.

- SKIN: No rash.

from emresource.org

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