Normal: Alert and oriented ×4 (person, place, time, situation). Well-nourished, well-developed. No acute distress. Cooperative and pleasant. Appropriate affect.
Document: Level of consciousness, body habitus, grooming, behavior, speech pattern.
Normal Ranges:
Normal: Normocephalic, atraumatic. Face symmetric. No tenderness, masses, or lesions.
Normal: PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation). EOMI (Extraocular Movements Intact). Anicteric sclerae. Conjunctivae pink and moist. Visual acuity intact.
Normal: Symmetric, no deformities. TMs pearly gray with light reflex. Hearing grossly intact bilaterally.
Normal: Midline, patent bilaterally. No drainage, polyps, or septal deviation. Mucosa pink and moist.
Normal: Mucous membranes pink, moist. Dentition intact. Tongue midline. Uvula midline, rises with phonation. No lesions or erythema. Tonsils non-enlarged.
Normal: Supple, full ROM. Trachea midline. No lymphadenopathy, JVD, or thyromegaly. Carotid pulses 2+ bilaterally without bruits.
Normal: Regular rate and rhythm. S1, S2 present. No S3, S4, murmurs, rubs, or gallops. PMI at 5th ICS MCL. Capillary refill <3 seconds. Peripheral pulses 2+ bilaterally.
Normal: Respirations unlabored. Chest symmetric. No accessory muscle use. Lungs clear to auscultation bilaterally. No wheezes, crackles, or rhonchi.
Normal: Soft, non-tender, non-distended. Bowel sounds active ×4 quadrants. No masses, organomegaly, or guarding. No rebound tenderness.
Normal: Full ROM all extremities. Muscle strength 5/5 bilaterally. No edema, deformities, or joint swelling. Gait steady and coordinated.
Normal: A&O ×4. CN I-XII intact. DTRs 2+ bilaterally. Sensation intact to light touch. No tremors, involuntary movements. Romberg negative. Coordination intact.
Normal: Warm, dry, intact. Good turgor. No rashes, lesions, bruising, or pressure injuries. Color appropriate for ethnicity.
Normal: Voiding without difficulty. Urine clear, yellow. No CVA tenderness.
Normal: Affect appropriate. Mood euthymic. Denies SI/HI. Support system identified. Coping skills adequate.
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