Documentation and Oral Presentation

Question 1

How do you express a normal state of appearance?

Answer 1

Alert and oriented; in no acute distress

Question 2

How do you describe someones head as being normal and without trama?

Answer 2

normocephalic and atramatic

Question 3

Describe a normal eye exam

Answer 3

PERLA, conjunctiva pink, sclera white, extraoccular movements intact.

Question 4

Describe a normal ear exam

Answer 4

External auditory canals patent, tympanic membrane intact

Question 5

Describe a normal nose exam

Answer 5

nares patent, no discharge, mucus pink

Question 6

Describe a normal mouth exam

Answer 6

oral mucosa pink, pharynx without erythema or exudate, tounge midline, dentition in good repair

Question 7

Normal neck

Answer 7

No lymphadenopathy, no mass

Question 8

Auscultation of the heart

Answer 8

Regular rate and rhythm (RRR)

Question 9

Normal pulmonary exam. What is the correct order, and how do you describe normal findings?

Answer 9

Inspection, palpation, percussion, and auscultation.

Clear to auscultation and percussion bilaterally. No chest wall deformity or asymmetry.

Question 10

Normal Abdominal exam. What is the correct order , and how do you describe normal findings?

Answer 10

Inspection, auscultation, percussion, and palpation

Soft, non-tender, normal active bowel sounds in 4 quadrants

Question 11

Structural exam, normal and abnormal findings

Answer 11

Landmarks of unlevelness-note the higher landmark
LMGL- note structures A&P to the line
Curves- normal kyphosis and lordosis, or flattened kyphosis.
Standing flex. test-document the + side
Seated flex. test-document the + side