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- GENERAL: Conversant and cooperative. In no acute distress.

- VITALS: Triage note and vitals reviewed.

- HEAD: Normocephalic. Atraumatic.

- EYES: Clear. No Discharge. No Photophbia

- ENT: No stridor, drooling, hoarse voice, swelling or trismus.

- NECK: No tracheal deviation. Not Tender. No Bruising.

- CARDIAC: Normal rate. Regular rhythm. Normal heart sounds.

- LUNGS: Effort normal. No Respiratory distress. No Splinting. No Wheezing. No Rales.

- CHEST: No tenderness

- ABDOMEN: Soft. No guarding. No rebound. Not Tender. No Bruising.

- EXTREMITIES: No Edema. No Tenderness. No deformity.

- NEURO: Alert and oriented. Non-focal. Normal speech.

- SKIN: Warm and dry. No erythema. No Abrasions

- PSYCHIATRIC: Normal mood and affect.

from emresource.org

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