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GENERAL PHYSICAL EXAMINATION: PERTINENT PHYSICAL FINDINGS/
PHYSICAL INJURIES
GENERAL PHYSICAL EXAMINATION
HEIGHT WEIGHT
GENERAL SURVEY
MENTAL STATUS
PERTINENT
PHYSICAL
FINDINGS/PHYSICAL
INJURIES
Include if possible:
� Nutritional status (optional)
� Ambulant/non-ambulant
� Respiratory distress/not in respiratory distress
� Other comments
Include if possible:
� Orientation as to time, place, person
� Consciousness, demeanor
� Developmental delay or mental retardation?
Include if possible:
� Injuries on the body 8
� Description of breasts 9
� Pregnancy-related findings
� Other abnormalities
8. Injuries
Contrary to commonly held beliefs, the exact time of a bruise’s infliction cannot be determined
accurately based on appearance. All that can be definitely stated is that if the color of the bruise is
yellow, the injury did not occur within the last 18 hours. Other colors may appear at any time from
within one hour of injury to resolution of the bruise, and so cannot be used to accurately date the age
of bruises. Further, bruises of identical age and cause on the same patient may vary in appearance and
change colors at different rates.
9. Description of Breasts
If the patient is female, describe her breasts according to the following categories:
Nipple
• Color (e.g., pink, light brown,
dark brown, darkly pigmented/
hyper-pigmented)
• Inverted, flat, protruding
• Physical injury (if any)
Areola
• Color
• Breast budding
• Physical injury
(if any)
Breast Tissue
• Prepubertal
• Developing
• Mature female
breast