Physical Exam Findings

Question 1

What 4 things do you document under General Constitutional?

Answer 1

1) Appearence (Normal = NAD or Appearance is normal)
2) Nourishment/Development (Normal = Well Nourished/Well-Developed)
3) Alertness (Normal = Oriented to time, place, and person)
4) Affect (Normal = Mood normal, Affect normal)

Question 2

What 6 things do you document under Integumentary System?

Answer 2

1) Skin temperature (Normal = Normal Skin Temperature)
2) Skin wet/dry (Normal = Skin is dry to touch)
3) Color (Normal = Normal color)
4) Rashes (Normal = No rash)
5) Skin intact (Normal = Skin is intact)
6) Signs of Infections (Normal = No signs of infections)

Question 3

What 3 things do you document on the head?

Answer 3

1) Signs of trama (Normal = Atraumatic, normocephalic)
2) Face appearance (Normal = Face is grossly normal)
3) Fontanelle (on peds) (Normal = Normal Fontanelle)

Question 4

What 6 things do you document on eyes?

Answer 4

1) Reaction to light (Normal = PERRL)
2) Eye muscles (Normal = EOMI)
3) Conjunctiva (Normal = Normal conjunctiva)
4) Schlera (Normal = Normal sclera)
5) Cornea (Normal = Normal cornea)
6) Eyelids and lashes (Normal = Eyelids and lashes appear normal)

Question 5

What 3 things do you document on ears?

Answer 5

1) TM’s
2) External Canals
3) Pinna

Question 6

What 4 things do you document on nose?

Answer 6

1) Nasal mucosa
2) Nasal discharge
3) Septum
4) Nostrils

Question 7

What 6 things do you document on oral pharynx/throat?

Answer 7

1) Lips/tongue
2) Oral mucosa
3) Posterior pharynx
4) Normal appearing tonsils
5) Normal dentition
6) Normal voice

Question 8

What 5 things do you document on the neck?

Answer 8

1) Appearance
2) ROM
3) Any palpable lymphadenopathies
4) Any thyromegalies
5) Any JVD or cartotid bruit

Question 9

What 4 things do you note in chest/lungs?

Answer 9

1) Any respiratory distress
2) Appearance and symmetry of chest
3) Lung sounds (Normal = clear)
4) Palpation findings (Normal = Normal to palpation)

Question 10

What 4 things do you document in Cardiac?

Answer 10

1) Auscultation and rate rhythm (Normal = Heart is normal to auscultation and Regular rate and rhythm)
2) Symmetry of peripheral pulses
3) Any Edema

Question 11

How is edema measured?

Answer 11

From Trace to 4+ pitting edema.

Question 12

What 4 things are documented in Abdominal?

Answer 12

1) Appearance
2) Results of palpation
3) Bowel sounds
4) Any CVA tenderness

Question 13

SI

Answer 13

Suicidal Ideation

Question 14

HI

Answer 14

Homicidal Ideation

Question 15

What should you note if a patient is positive for SI or HI?

Answer 15

If they are with or without a plan?

Question 16

Where is Flight of ideas noted?

Answer 16

In Psychiatric under thought processes

Question 17

Which sections are not normally selected in the general adult physical template?

Answer 17

1) Psychiatric
2) Genitourinary
3) Abdominal

Question 18

On what scale is strength measured in the motor skills section of Neurogical? What is normal strength?

Answer 18

1-5 out of 5 ; 5/5 is normal strength.

Question 19

Which tendons are most commonly checked in DTR test?

Answer 19

Patella, Achilles, and Biceps

Question 20

What is Homan’s sign used to diagnose?

Answer 20

Thrombosis in lower leg

Question 21

Where is Homan’s sign documented/

Answer 21

Musculoskeletal

Question 22

Where are Valgus and Varus tests documented? What do they test?

Answer 22

Musculoskeletal; Valgus = ligament damage, Varus=joint laxity on outside of knee

Question 23

What is McMurray’s test? Where is it documented?

Answer 23

Tests for damage to meniscus of knee; documented in Musculoskeletal

Question 24

What 5 tests are documented in Abdominal findings?

Answer 24

1) Murphy’s sign (gall bladder)
2) McBurney’s Sign (appendix)
3) Psoas Sign (Appendix)
4) Obturator’s Sign (Appendix)
5) Rovsing’s Sign (Appendix)

Question 25

Where is edema noted?

Answer 25

Cardiac findings

Question 26

What does bibasilar mean?

Answer 26

At the base of both lungs

Question 27

What tests are documented in Neck?

Answer 27

1) Kernig’s Sign

2) Brudzinski’s Sign

Question 28

What is a benign, painless bump on the eyelid?

Answer 28

Chalazion

Question 29

Where is Hordeolum documented? What is it?

Answer 29

Eyes; an infection of the eyelid

Question 30

What kind of rashes disappear when pressed?

Answer 30

Blanching

Question 31

What kind of rashes do not disappear when pressed?

Answer 31

Non-blanching