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Guide in Reporting Complete Physical Examination (2013) - Source: Bates' guide to physical examination.

Guide in Reporting Complete Physical Examination (2013) - Source: Bates' guide to physical examination.

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Guide in Reporting Complete Physical Examination of medical students and other health care professionals.

Physical Examinations includes:
1. General survey
2. Vital signs
3. Skin
4. Head & Neck
5. Thorax & Lungs
6. Cardiovascular
7. Abdomen
8. Neurological
9. Musculoskeletal
Guide in Reporting Complete Physical Examination of medical students and other health care professionals.

Physical Examinations includes:
1. General survey
2. Vital signs
3. Skin
4. Head & Neck
5. Thorax & Lungs
6. Cardiovascular
7. Abdomen
8. Neurological
9. Musculoskeletal

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Categories:Types, School Work
Published by: Ernie G. Bautista II, RN, MD on Aug 03, 2013
Copyright:Attribution Non-commercial

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01/10/2016

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

COMPLETE PHYSICAL EXAMINATION GENERAL SURVEY: Awake and alert; properly groomed; friendly and cooperative; short & slender; fairly nourished; speaks in a slow, moderate tone of voice; oriented to time, place and person; no gross deformity; with normal/ erect post and gait. VITAL SIGNS:     SKIN: The skin is (brown/black), smooth & dry, with normal elasticity, mobility and thickness; No visible superficial blood vessels & lesions not noted; With black scanty, fine & well distributed hair; Nails are slightly pink, smooth, normal nail folds & lesions not noted. HEAD AND NECK: I. HEAD Cranium: Hair is black, dry & evenly distributed; with normocephalic, symmetric, no deformities, no swelling, no tenderness; temporal arteries are not visible but palpable with equal & strong pulsations and walls are not thickened. Face: Oval, symmetrical, normal facie, no lesions & no involuntary movements. Eyes:         Eyebrows are black, fine, fairly abundant & evenly distributed; No edema of the eyelids, no ptosis, no tremors and negative lidlag; With symmetric and normal palpebral fissure; With fine, outward direction of growth & no matting of the eyelashes; Negative for exophthalmos & enophthalmos; With pink conjunctiva & white sclera; no lesions noted; With transparent cornea & no lesions noted; Iris is dark brown & flat; T = ___ degree Celsius PR = ___ bpm RR = ___ cpm BP = ___ mmHg

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

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Pupils are 4-5 mm, it is round & both equally reactive to light and with normal accommodation; With transparent lens; Fundoscopic examination reveals: (+) ROR with an A:V ratio of 2:3 and optic disc is distinct with clear margin.

Ears:     Auricles are normal in size & shape, symmetric, no lesions, no tenderness No tenderness over the mastoid area External ear canal is patent, walls are not hyperemic, no lesions & with minimal dry discharge Tympanic membrane: pearly white, intact, translucent, w/ visible cone of light & malleus, no bulging, no retractions Nose & Paranasal Sinus:     Symmetric, no deformity, no flaring of ala nasi; Nasal septum: with pink mucosa, no lesions, straight in midline & no perforation; Nasal cavity: patent, with pink mucosa, no discharge, turbinates not congested; No tenderness & positive transillumination both in frontal & maxillary sinus

Oral cavity:          Lips are pink, symmetric, slightly moist, no lesions; Labial mucosa: pinkish, no pigmentation, no lesions Bucal mucosa: smooth, shiny, no pigmentation, no lesions, gums are pink; Soft & hard palate: pinkish & no lesions; Teeth: complete set of teeth, no dental carries, slightly discolored teeth, no bridges/ braces; Tongue: normal in size & shape, symmetric, midline when protruded, pink with white thin coat & can move from side to side Uvula in midline; Tonsils are not enlarged & no exudates; Posterior pharyngeal wall is pink & with no exudates

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

II. NECK Normal in size, symmetrical, normal muscle tone, no tenderness, no visible mass, with full range of motion; trachea in midline, no palpable superficial & deep lymph nodes, thyroid gland is not visible or palpable. THORAX AND LUNGS Inspection The chest is brown, no lesions, no visible dilated vessels, with normal muscle development; Thorax is symmetric, elliptical, no deformity; With normal rate of respiration, effortless breathing, with inspiratory phase longer than expiration, & with symmetric lung expansion Palpation No tenderness, no palpable mass; Symmetrical chest expansion both in upper & lower lung field; Normal & equal tactile fremitus on both sides anteriorly, laterally & posteriorly Percussion Normal lung percussion note: The entire lung area is resonant Auscultation Breath sounds are vesicular on the entire lung area except beneath manubrium sterni & upper interscapular region (bronchovesicular); Negative for adventitious sound; Negative bronchophony, egophony, and whispered pectoriloquy. CARDIOVASCULAR Inspection & Palpation:  Neck vessels: Jugular veins are not distended; Carotid arteries have strong, regular, equal pulsations, & with soft consistency of the walls  Precordium: Flat, apex beat located 5th ICS at 1-2 cm medial to the LMCL, visible and palpable but normal in size and amplitude, no thrust or lift, no palpable heart sounds, no thrills

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

Auscultation: Normal rate and rhthym, normal S1 & S2, no extra heart sounds, no murmurs

ABDOMEN Inspection:  Skin is brown, no lesions, no scars; it is symmetric, no localized bulging, no swelling; shape is flat & umbilicus is inverted; no visible peristalsis, no superficial dilated veins, no abnormal pulsations. Auscultation:  Normoactive bowel sounds, no bruit heard over the epigastrium, right & left paraumbilical areas. Percussion:  The four quadrants are tympanitic; the liver span is 6cm and no splenic dullness; no fluid wave, no shifting dullness; no CVA tenderness. Palpation:  On light palpation, the abdomen is soft, no palpable superficial mass & tenderness; On deep palpation, no deep mass & tenderness. The liver, spleen, right & left kidneys are not palpable NEUROLOGICAL I. Cerebrum:  Conscious and coherent, with a GCS of 15. Cooperative, appropriately groomed, has no mannerisms. Oriented to time, place, person, with intact recent, immediate and

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

remote memory. Language is fluent, was able to repeat a series of digits, and was able to follow verbal and written commands. Was able to identify objects by palpation, recognize objects by its sound and by vision and was able to recognize own body parts.

II. Cranial Nerves:   CN1: Both nostrils are intact and was able to identify test substances CN2: Opthalmoscopy reveals +ROR, clear media, distinct disc margin, normal AV ratio, no hemorrhages; normal visual acuity & confrontation test.    CN3: (+) direct and indirect light reflex, normal convergence and no ptosis CN4&6: Intact extraocular muscles, no nystagmus CN5: Able to identify pain stimulus and light stimulus and was felt equally on both sides, (+) corneal reflex, equal contraction of temporalis and masseters on both sides, (-) jaw jerk reflex  CN7: Able to identify test substances, symmetrical and equal contraction of muscles of facial expression    CN8: No lateralization on weber test, no nystagmus, negative Romberg test CN9&10: No dysphonia nor dysarthria, uvula at the midline, (+) gag reflex CN11: Able to turn head from side to side against resistance, can elevate shoulders equally  CN12: No atrophy nor fascicualtions, tongue at midline, was able to move tongue from side to side

III. Cerebellum:  Normal finger-nose-finger, heel to shin test, & can do rapid alternating movement; normal tandem gait, & (-) romberg test.

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

IV. Motor Function:  No atrophy, fasciculation nor involuntary movement, normal muscle tone with 5/5 muscle strength on all extremities

V. Sensory Function:  Can feel pain & light touch equally on both sides & with normal position sense

VI. Reflexes:  (+) abdominal reflex, biceps, triceps, knee jerk and ankle jerk reflex was graded as 2+; (-) for babinski, clonus and hoffman sign.

VII. Gait: Normal posture. Can walk on toes and on heel.

VIII. Meningeal Signs: No nuchal rigidity, negative brudzinsky and kernig sign. MUSCULOSKELETAL: I. Head and Neck  TMJ is symmetrical, no swelling, redness, tenderness, crepitation or snapping with normal ROM  With concave cervical spine & symmetrical with normal muscle tone & no tenderness

II. Hands and Wrists  Inspection: no visible deformities, redness, swellings, bony enlargement, nodules & muscle atrophy   Palpation: no bogginess, swelling & tenderness on the wrists, MCP, PIP & DIP joints ROM: Normal ROM of the joints of wrist & hand

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

III. Elbows   Inspection: No visible deformities, redness, swellings & nodules; Palpation: No bogginess, swelling nor tenderness on elbow joint. No thickening of synovial membranes  b Normal ROM of all elbow joints

IV. Shoulders  Symmetrical contour, no tenderness on the joints, muscles & tendons. No crepitus. Normal range of motion

V. Hips:  Normal gait, symmetrical legs, normal muscle development, no deformities, no tenderness   No limitations in ROM (-) thomas test, (-) trendelenburg test, (-) Patrick test, (-) gaenslen test

VI. Knees:  Inspection: quadriceps  Palpation: no warmth, tenderness, crepitus, thickening or swelling over the joints, bursae, meniscus & ligaments   ROM: full range of motion Special maneuvers: (-) patellofemoral grinding, bulge sign, balloon sign, McMurray test & anterior & posterior drawer sign no erythema, swelling, malalignment, deformities, atrophy of

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GUIDE IN REPORTING NORMAL PHYSICAL EXAMINATION

2013

VII. Feet:  Inspection: no visible deformities, callus, corns, redness, swellings, nodules & misalignments  Palpation: no bogginess, thickening, swelling nor tenderness on the ankle joint. No palpable nodules & tenderness on the Achilles tendon, metatarsophalangeal joint & interphalangeal joints  ROM: Normal ROM of all the ankle joints

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