Title | Verbal Trigger | Content |
Normal abdomen | Normal abdominal examination | Abdomen: Soft and non-tender, normal bowel sounds in all four quadrants, no palpable masses. No hepatosplenomegaly. No costovertebral angle tenderness. |
Neurological examination | Normal neurological examination | Neurological examination: Awake, alert, and oriented. Pupils equal and reactive to light. Normal facial motor function. Symmetrical strength and sensation in all extremities. No focal neurological deficits. Normal gait and coordination. Finger-to-nose test normal. Heel-to-shin test normal. Negative Romberg test. Plantar reflexes downgoing. |
Lung auscultation | Normal breath sounds | Normal respiratory rate. No wheezes or crackles. Vesicular breath sounds bilaterally at the lung bases. |
Cardiac examination | Normal heart sounds | Heart: Regular rhythm with peripheral pulse equal to apical rate. Normal heart sounds, no murmurs. No aortic stenosis murmur. |