Presenting examinations Flashcards
Cardiovascular
“Today I performed a cardiovascular examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
There was no peripheral stigmata of cardiac pathology.
The pulse was [XXbpm] and was of normal rate and rhythm.
On palpation, there were no heaves and thrills.
On auscultation, 1st and 2nd heart sounds were present with [no added sounds/describe murmurs].
To conclude, this is consistent with [diagnosis/a normal cardiovascular examination]”.
Knee
“Today I performed a knee examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
No abnormalities were detected on inspection.
There was normal gait.
On palpation, there was no tenderness.
Full range of movement in all modalities tested.
Special tests were negative.
To conclude, this is consistent with [diagnosis/a normal knee examination]”.
Shoulder
“Today I performed a shoulder examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
No abnormalities were detected on inspection.
On palpation, there was no tenderness.
Full range of movement in all modalities tested.
Special tests were negative.
To conclude, this is consistent with [diagnosis/a normal shoulder examination]”.
GALS
“Today I performed a GALS examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
Normal appearance in gait, arms, legs and spine.
Full range of movement in all modalities tested.
To conclude, this is consistent with [diagnosis/a normal GALS examination]”.
Hip
“Today I performed a hip examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
No abnormalities were detected on inspection.
There was normal gait.
On palpation, there was no tenderness.
Full range of movement in all modalities tested.
Special tests were negative.
To conclude, this is consistent with [diagnosis/a normal hip examination]”.
Respiratory
“Today I performed a respiratory examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
There was no peripheral stigmata of respiratory pathology.
The pulse was [XXbpm] and was of normal rate and rhythm.
The respiratory rate was XX breaths/minute.
There was no evidence of fine or flapping tremor.
On palpation, there was symmetrical chest expansion and no evidence of mediastinal shift.
On percussion, all lung fields were resonant.
On auscultation, vesicular breath sounds were present bilaterally with no added sounds.
To conclude, this is consistent with [diagnosis/a normal respiratory examination]”.
GI
“Today I performed an abdominal examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
There was no peripheral stigmata of gastrointestinal pathology.
The abdomen was soft and non-tender.
There was no evidence of organomegaly.
Bowel sounds were present and normal with no bruits detected.
To conclude, this is consistent with [diagnosis/a normal abdominal examination]”.
Hand
“Today I performed a hand examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
No abnormalities were detected on inspection.
On palpation, there was no tenderness.
Full range of movement in all modalities tested.
Sensation was intact.
Special tests were negative.
To conclude, this is consistent with [diagnosis/a normal hand examination]”.
Lower Limb
“Today I performed a lower limb neurological examination on [name] a [age] year old [gender].
On general inspection… (include meningeal irritation).
On examination of…
Tone.
Power.
Reflexes.
Sensation.
Coordination.
To conclude, this is consistent with [diagnosis/normal lower limb neurological examination]”.
Upper
“Today I performed a lower limb neurological examination on [name] a [age] year old [gender].”
On general inspection… (include meningeal irritation).
On examination of…
Tone.
Power.
Reflexes.
Sensation.
Coordination.
To conclude, this is consistent with [diagnosis/normal upper limb neurological examination]”.
Thyroid
Today I performed a thyroid exam on xxx
On general inspection they seemed comfortable at rest
On examination there were no peripheral stigmata of thyroid pathology.
The pulse was xx bpm
There was no evidence of tremor
No evidence of thyroid eye disease, goitre or other swelling
On percussion there was no evidence of retrosternal goitre
No evidence of bruits
Normal thyroid examination
Cerebellar
“Today I performed a cerebellar examination on [name] a [age] year old [gender].
On general inspection…
On examination of…
Gait
Arms
Head
Legs
To conclude, this is consistent with [diagnosis/normal cerebellar examination
Varicose vein
“Today I performed a varicose vein examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
There was no peripheral signs of venous insufficiency in the legs.
Both the cough test and tap test were negative.
To conclude, this is consistent with [diagnosis/a normal varicose vein examination]”.
Upper P Vasc
“Today I performed an upper limb peripheral arterial examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
There was no peripheral stigmata of peripheral arterial disease.
Pulses were present bilaterally in the upper limb and had normal rate, rhythm + character with the pulse being XXbpm.
Abdominal aortic pulse was not palpable and there were no audible bruits.
To conclude, this is consistent with [diagnosis/a normal upper limb peripheral arterial examination]”.
DF
“Today I performed a diabetic foot examination on [name] a [age] year old [gender].”
On general inspection, [name] appeared comfortable at rest.
No abnormalities were detected on inspection.
Gait was normal
On palpation, there was no tenderness.
Sensation was intact in both feet –
If lost say where it was lost up to.
To conclude, this is consistent with [diagnosis/a normal shoulder examination]”.
