Types of Physical Exams

Question 1

Types of Physical Exams

Answer 1

• External Exam
• Basic Exam
• Detailed Exam

Question 2

External exam

Answer 2

• clues gathered at first glance
• no touch involved
• part of basic exam that most physicians perform
• document in each respective part, ie Constitutional (NAD), eyes (PERRL, EOMI=external ocular movement intact), neck (supple/flexible, no lymphadenopathy), CV, respiratory, abdominal (RLQ = right lower quadrant, extremities (full ROM = range of motion), skin (dryness, rashes, warmth), neurological (alert, oriented, speech), psychiatric (normal affect/emotional state)

-physical exam is organized by body system

Question 3

More details of external exam

Answer 3

General / Constitutional = does the patient look like they’re in pain, are they malnourished, are they well developed

Eyes = is their sclera yellow or red

Pulmonary = do they appear to be breathing comfortably, or are they having respiratory distress

Skin = is their skin a normal color?

Neurological = are they answering q’s appropriately

Psychiatric = are they acting normally

Question 4

Basic Exam

Answer 4

-starts w/ external exam (no touch), +…

• auscultation of heart
• auscultation of lungs
• palpation of abdomen- look for tenderness
• examination of legs- look for edema/swelling

Question 5

Detailed Exam

Answer 5

• Neurological exam
• -patient has headache, weakness, facial droop, altered mental status, neck pain, recent trauma
• Gynecological exam
• -females with pelvic pain, vaginal bleeding/discharge, or pregnant females
• Eye pain, redness, watering
• –could be allergies

Detailed neurological test
-motor movement, ataxia, gait
-pronator drift = lift hands up, upper motor neural weakness- pronation of affected arm
-check CN's
-romberg test = take off shoes, stand w/ 2 feet together with eyes open, then closed- count time patient can do so w/ eyes closed
(neg = stable)
(pos = dorsal column disease)
-check for benign positional vertigo

Question 6

Benign external exam

Answer 6

General = well developed, nourished, NAD
Eyes = PERRL
ENT = moist mucosa
Neck = supple
CV = well perfused
Respiratory = no resp distress
GI = non-distended
Extremities = no edema
Skin = dry, no rashes
Neurological = alert, oriented, normal speech
Psychiatric = normal affect

Question 7

Benign Complete Exam

External/No-touch + Touch

Answer 7

General = well developed, nourished, NAD
Eyes = PERRL, *EOMI
ENT = moist mucosa
Neck = supple, *no lymphadenopathy
CV = well perfused, *regular rate/rhythm, *no murmurs, gallops, rubs, *distal pulses intact
Respiratory = no resp distress, *clear to auscultation bilaterally, *no wheezes, rails, or rhonchi
GI = non-distended, *soft, *non-tender, *no guarding, rebound, rigidity
Extremities = no edema, *full ROM (range of motion)
Skin = dry, no rashes, *warm
Neurological = alert, oriented, normal speech
Psychiatric = normal affect

Question 8

Documentation template

Answer 8

• tabs organized by body system
• if a doctor doesn’t investigate something, remove that finding
• unique exams are left blank on a pre-filled template, fill it out only if performed- ex) extensive neurological exam, genital exams, detailed eye exams
• avoid contradictions, esp when adding comments

Question 9

NVD

Answer 9

nausea, vomiting, diarrhea

c = constipation