Lu

Nervous System

Mental Status Cranial Nerves Motor System Sensory System Reflexes Additional Examinations

Rectal Examination In Men Genital and Rectal Examination In Women RECORDING YOUR FINDINGS

Tips for a Clear and Accurate Write-Up Order of the Write-Up Degree of Detail Example of Mrs. N

Chief Complaint Present Illness Past History

Childhood Illnesses Adult Illnesses Health Maintenance Family History Personal and Social History Review of Systems General Skin

Head, Eyes, Ears, Nose, and Throat (HEENT)

Neck

Breasts

Respiratory

Cardiovascular

Gastrointestinal

Urinary

Genital

Peripheral Vascular

Musculoskeletal

Neurologic

^S Hematologic

O Endocrine

^^ Psychiatric

Physical Examination C Vital Signs

O Skin

Head, Eyes, Ears, Nose, and Throat (HEENT) Neck

^ Lymph Nodes

Thorax and Lungs

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