Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the head, neck, and thyroid.

• The head is normocephalic without evidence of trauma. The neck is supple, with full range of motion. No adenopathy is present in the neck. The thyroid is nontender and is not enlarged. No thyroid nodules are felt.

• The head is normocephalic and atraumatic. There is a 2-cm, rubbery, nontender mass in the superficial cervical chain on the left side. The mass is freely mobile and is not fixed to the skin or underlying muscle. Another 4-cm, rubbery, nontender mass is felt in the right supraclavicular fossa. The thyroid is unremarkable.

• There is frontal bossing of the head with prominence of the cheek bones. There is no evidence of trauma. The neck is supple, with no adenopathy present. There is a 2-cm, soft, painless thyroid nodule felt 3 cm from the midline in the upper portion of the right lobe (at approximately the 10 o'clock position). The nodule is not fixed to the overlying skin or muscles.

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