Guidelines On The Proper Recording of Physical Examination Findings
Guidelines On The Proper Recording of Physical Examination Findings
Guidelines On The Proper Recording of Physical Examination Findings
Location
Distribution
Patterns
Shape
Type
Color
Hairs
Nails
Example:
1. The skin is fair in color, moist, warm to touch and smooth. It is
elastic with good skin turgor. A circular scar of about 2.5cm noted
between the left thumb and index finger on the dorsal aspect and a
tattoo on the right deltoid area. The hair are black and equally
distributed in the head while the nails are clean with pinkish beds
and capillary refill time of less than 2 sec. no clubbing noted
2. Generalized icteresia of the skin noted, dry, very warm and coarse.
It is elastic with decrease skin turgor. An erythematous ulcer with a
diameter of 3cm noted in the dorsal aspect of the left foot with foul
smelling discharge. The hairs are evenly distributed, thick and
black.
The nail beds are pale with capillary refill of 8 sec.
Shamroths test is present.
Head: High School Stint, Forever Special
Hair
Scalp
Skull
Face
Skin
Example:
1. The hairs are black, thick, evenly distributed, no scales or lumps
noted. The head is round with no depressions, no tenderness. The
face is symmetrical with no involuntary movements while the skin
is white with no obvious lesions
2. The hairs are thin with frontal baldness; seborrheic scales were also
present. The skull is symmetrical with moon-fascie appearance.
Fine hairs are also present in the face with facial plethora and acneform lesions.
The Eyes: Peaches & Almonds, Eat Everything Leisurely: Cakes &
Salad, Chicken & Lambs, Ice cream, Pizzas, Chocolates, Egg pies,
Lollipops, Candies, Fruits
Position & Alignment of the Eyes
Confrontation test
Eyebrows
Extra ocular movement
Eyelids
Lid Lag
Lacrimal apparatus
Convergence test
Conjunctiva & Sclera
Fundoscopy
Cornea & Lens
Iris
Pupils
Examples:
1. The eyebrows are symmetrical with equally distributed fine hairs.
The upper lids are symmetrical occupying the upper 1/3 of eyeballs.
The medial canthi are not swollen. The sclerae are white with
pinkish palpebral conjunctiva. The cornea and lens are clear with
well-defined borders of the iris. The pupils are equal about 2-3 mm
in size reactive to both direct and consensual reflex. No visual
defects noted on confrontation test; the EOMs are intact and
positive convergence test. The red orange reflex was noted on
Fundoscopy. The optic disc is yellowish orange in color with welldelineated physiologic cup located centrally with AV ratio of 2:3, no
hemorrhage, exudates noted in the surrounding fundi.
2. The eyebrows are symmetrical with lateral thinning of hairs,
drooping of upper eyelid noted in the left eye, swollen medial
canthus of the left eye with purulent fluid discharge. Icteric sclerae
with pale palpebral conjunctiva. Corneal opacities are present on
both eyes with ill-defined margin of the iris. The pupil are equal
about 2-3 mm both reactive to direct and consensual reflex. No
visual defects noted on confrontation test, intact EOMs, positive
convergence test with lid lag of the left eye. Red-orange reflex not
appreciated on Fundoscopy
The Ears: Animal: Elephants & Dogs, Alligators & Birds
Auricle
Ear canal & Drum
Air & Bone conduction
Example:
1. The ears are symmetrical, non tender auricle and negative tug test.
Otoscopy showed absence of redness and swelling of the ear canal.
Lymph nodes
Trachea
Thyroid
Distension of neck veins
Example:
1. Neck is slender, supple, non-tender with no palpable mass or lymph
adenopathy. The trachea is in the midline while the thyroid gland is
diffusely enlarged, about 25 gm in weight, firm, non-tender and
moves with deglutition, no bruit noted.
2. The neck is short and broad, with visible horizontal surgical scar,
palpable lymph adenopathy on submandibular areas, firm, mobile
matted and non tender. The thyroid gland is not palpable
Chest and Lungs
Inspection: Start Showing Dedication Regarding Lessons Worth
Remembering
Shape
Symmetry
Deformities
Respiratory movements
Lagging
Widening of intercostals space
Retraction
Palpation: Cool Teachers Must Teach
Chest expansion
Tactile fremitus
Mass
Tenderness
Percussion: Resonance
Auscultation: Be Vigilant To Anyone
Breath sounds
Vocal fremitus
Transmitted voice sounds
Adventitious sound
Example:
1. The thorax is elliptical in shape, symmetrical in expansion with no
deformity, widening of intercostals space, retractions and skin
lesions. The breathing is quiet and regular with no use of accessory
muscles of respiration.
Equal chest expansion on palpation as well as the tactile fremitus
on both lung fields posteriorly and anteriorly.
There was no
palpable mass or area of tenderness.
On percussion, the lung fields are predominantly resonant except
the cardiac area anteriorly and the scapular areas posteriorly
The breath sounds are predominantly vesicular in both lung fields
anteriorly and posteriorly except the area of the trachea and the
manubrium which are tracheal and bronchial in nature. Vocal
fremitus are equal on both lung fields anteriorly and posteriorly with
no adventitious sounds noted, no bronchophony, egophony and
whispered pectoriloquey appreciated.
2. JVP is 12cm above the right atrium, weak carotid pulses and the
upstroke undetected.
Hyperdynamic precordium, PMI at 6th ICS midaxillary line, no
precordial bulging, visible skin lesion, or mass noted.
The apical beat noted at the 6th ICS (L) mid axillary line with
palpable thrills noted at the aortic area.
The heart rate is 72/min with irregularly irregular rhythm. Faint
heart sound in the apex while S1 is greater than S2 in the base
noted.
A grade 4/6 harsh murmur noted at the 2 nd ICS (R)
parasternal line which is systolic in timing
Abdomen:
Inspection: Social Security System Are Paying People Unsatisfactorily
Shape
Symmetry
Skin and obvious Lesions
Abdominal breathing
Pulsations
Peristalsis
Umbilicus
Auscultation: Beer-Belly Boy Friend
Bowel sound
Borborygmi
Bruits
Friction Rub
Percussion: Apple Likes To Cha-cha
Abdominal tympani and dullness
Liver span
Traubes space
Costovertebral angle
Palpation:
Light palpation: Cottony And Soft
Consistency
Area of tenderness
Superficial masses or organs
Deep palpation Leave Room, Dine Out
Liver edge
Rebound tenderness
Deep masses
Organomegaly (liver, spleen, kidneys, bladder and aorta)
Special Techniques
Ascites (if abdomen is protuberant with bulging flanks) Fluid
Sinks
Fluid wave test
Shifting dullness
Appendicitis: DR Roland Please Order Chicken
Direct tenderness
Rebound tenderness
Ravings sign
Psoas sign
Obturator sign
Cutaneous hyperesthesia
Acute Cholecystitis: Mine
Murphys sign
Example
1. The abdomen is flat, symmetrical with an abdominal girth of 79cm,
no bulging flanks nor visible skin lesions noted. It moves with
respirations with no visible pulsation or peristaltic movement.
Umbilicus at the midline, inverted with no bulging.
The bowel sounds are 16/mm with no borborygmus. No bruit noted
to the areas corresponding to the aorta, renal and iliac artery. No
friction rubs in the hepatic or splenic area.
It is tympanitic in all quadrants, liver span of 8cm midclavicular line
right, Traubes space not obliterated and negative kidney punch
test.
On light palpation, the abdomen is soft in all quadrants with no area
of tenderness nor superficial masses and organs appreciated. The
liver edge is smooth with regular borders, no rebound tenderness
nor deep masses on all quadrants. The spleen, kidney, bladder and
aorta are not palpable.
Special tests are absent.
2. The abdomen is globular and protuberant with bulging flanks. The
abdominal girth is 38 inches. It moves with respiration with visible
pulsations and peristaltic movements. The umbilicus is everted and
midline. The bowel sounds are hyperactive at 40 sounds/min with
borborygmi. Abdominal bruit noted at the midline of epigastric
area. No friction rib in the area of the liver and spleen, both lower
quadrants are dull while the rest are tympanitic, liver span at 5 cm
right perasternal line, Traubes space is tympanitic with no
costovertebral angle tenderness. All quadrants are soft but with
direct tenderness on right upper quadrant. No superficial mass or
organ palpated. Fluid wave test and shifting dullness on both lower
quadrants are noted. Murphys sign is also present. Special
techniques for acute appendicitis were not appreciated.
external and internal rotation without difficulty. The leg raising test
and Patricks test are negative.
Knee: symmetrical with no swelling or redness noted. No area of
tenderness or crepitus appreciated. Can do flexion, extension,
internal and external rotation without difficulty.
Ankle and foot: the surfaces are smooth with not obvious lesions. The
dorsalis pedis and posterior tibial pulses are equal. No swelling or
tenderness noted; can do flexion and extension, inversion and
eversion without difficulty.
Neuro: Men Can Make Scenarios Doing Challenging Moments
Mental Status: A Monkey On Pillow Talking To Iguana,
Joyfully And Merrily
Laughing Haha
Attention
Memory
Orientation
Perception
Thought processes
Thought content
Insight
Judgment
Affect
Mood
Language
Higher cognitive function
Cranial nerves assessment
Motor functions
Sensory functions
Deep tendon reflexes evaluation
Cerebellar functions
Meningeal signs
Example:
MSE
Patient is alert, very attentive and can maintained eye contact
when asked. Remote and recent memories are very sharp, oriented
to time, place and person. No illusion or hallucinations. He is
coherent and very anxious on what will happen to him, citing that
this the main reason why he sought consultation. His responses to
family or personal situation are appropriate. He is very cooperative
but at times seems worried and sad.
He is very talkative, his speech is fast, loud and clear and fluent.
Patient calculate mathematical problem easily. Could interpret
proverbs relevantly with intact construction ability when ask to
draw a clock face.
Cranial Nerves:
I
can smell coffee on both nostrils
II
no visual defects on confrontation test
the optic discs on fundoscopy are yellow with welldelineated borders
and centrally located physiologic cup
III
pupils reactive to light
III, IV, VI intact EOMs
V
can clench his teeth with positive corneal reflex on both
eyes
VII
symmetrical face can raise both eyebrows, can smile
and frown and
puff out both cheeks
VIII
can hear snapping of fingers at a distance of 1 foot on
both ears
IX, X
can swallow with difficulty
gag reflex present
XI
can snug both shoulders
XII
can to tongue protrusion
100%
5/5
5/5
5/5
5/5
100%
100%
100%
100%
100%
++
++
++
++
Intact
position, vibration & temperature sense; no Babinski reflex or ankle
clonus
Cerebellar
Can do tandem walking, fingers to nose test with good coordination
Rombergs test is negative
Menigeal
No nuchal rigidity
(-) Kernergs sign, (-) Brudzinskis sign