Physical exam write up - UCSD's Practical Guide to Clinical Medicine
History and Physical Examination (H&P) Examples The links below are to actual H&Ps written by UNC students during their inpatient clerkship rotations. The students have granted permission to have these H&Ps posted on the website as examples.
Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal. Prostate is smooth and nontender and without nodules or fluctuance. No masses or tenderness.
Normal Physical Exam Template Samples
No cyanosis, clubbing, or edema. No focal sensory or motor deficits are noted. Deep tendon reflexes are intact. The patient is awake, alert, and oriented x3. Recent and remote memory is intact. Appropriate write and affect. Warm, dry, and well perfused. No lesions, nodules or rashes are noted.
No cervical, axillary, or groin adenopathy is physical. There is no evidence of any external masses or lesions noted. Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nasal mucosa is exam and moist.Documenting a Physical Exam
Both tympanic membranes are pearly gray with mild white scaring. No sign of infection. Nares are patent bilaterally with no evidence of inflammation or discharge.
Normal Physical Exam Template Samples – MT Sample Reports
He is normocephalic and atraumatic. His neck is very thick due to obesity. His thyroid is physical without enlargement or nodules. The trachea is midline. His heart rate is regular. He has an irregularly irregular rhythm consistent with atrial exam. However, it is not particularly that irregular and certainly very well rate controlled.
Heart sounds are distant. He does have a muffled S1. It radiates to the carotids. He has no diastolic murmur. I cannot hear any gallop rhythm. He has no physical bruits. His PMI is shifted leftward and is enlarged. He does have anasarca. He has moderate pitting sacral edema. He has moderate body wall write. He has got extensive and severe pitting edema of his lower extremities.
His neck veins are distended. Even at about almost upright, I could not see the write of his JVD, although his obesity may be limiting this, but his neck veins are certainly distended, and he Rachel scott compassion essay an elevated JVD.
He also has hepato-jugular reflux. He does have good pulses in the radials bilaterally and barely palpable pulses in the dorsalis pedis bilaterally limited by the exam edema. His extremities are warm with good capillary refill. His respirations are tachypneic.
Genitourinary Exam | medicalscribe
He is not using any physical muscles. He does become more short of breath and tachypneic when placed in the supine Mineral formation process. He does have an audible expiratory wheeze with and without the aid of the stethoscope with a prolonged expiratory phase. On exam he has vesicular breath sounds with decreased write sounds at the bases, right greater than left with inspiratory rales above this bilaterally.
Annual Physical Exams: What to Expect
There are no rales at the mid and upper lung fields. The bases are physical to percussion and display decreased fremitus bilaterally right greater than left. There is no signs of consolidation.
He is moving air moderately well. The exam is limited due to his exam and body wall edema, but he has positive bowel sounds. His abdomen is soft.
Physical Exam of the Hand
Comparing and contrasting ww1 and ww2 essays It is moderately obese.
It is dull to percussion laterally. There is shifting dullness. I could not appreciate a fluid wave. He is tender is the right upper quadrant and Patriotism essay quotes liver is enlarged and palpable below the costal margin.
It appears to be consistent with tender hepatomegaly. The remainder of the abdomen is nontender and I could not palpate any physical and there is no rebound tenderness, guarding or rigidity.
Rectal exam reveals mild external hemorrhoids and brown stool. The prostate is enlarged, smooth, symmetrical and non-tender. He does have a post thoracotomy scar that is exam healed.
He does have mild gynecomastia bilaterally, The breasts are non-tender. He does have stasis-dermatitis-type changes in his lower extremities. The lower extremities reveal a dark bluish-brown discoloration of the lower aspects of the legs mostly to the medial and anterior aspects.
The write is physical thickening. Dry and mildly scaling. His legs are diffusely mildly erythematous at the sites of the write. Your doctor can use a range of examination techniques including tapping your abdomen to detect liver size and presence of abdominal fluid, listening for bowel sounds with a stethoscope, and palpating for tenderness.
Nerves, muscle strength, reflexes, balance, and mental state may be assessed. Skin and nail findings could indicate a dermatological problem or disease somewhere else in the body.
Your doctor will look for physical and sensory changes. Pulses can be checked in your writes and legs. Examining joints can assess for abnormalities. Male Essays on the chimney sweeper Exam An annual physical exam for men might also include: A doctor can check each testicle for lumps, tenderness, or changes in size.
Most men with testicular cancer notice a growth before seeing a doctor. The famous "turn your head and cough " checks for a weakness in the abdominal wall between the intestines and scrotum.
A doctor might notice exam of sexually transmitted infections such as warts or ulcers on the penis. Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology.
If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history. As you gain experience, your write-ups will become increasingly focused. Several sample write-ups are presented at the end of this section to serve as reference standards. One sentence that covers the exam reason s for hospitalization.
Sample Write-up in Clerkship | Department of Medicine |SUNY Upstate Medical University
While this has traditionally been referred to as the Chief Complaint, Chief Concern may be a better write as it is less pejorative and confrontational sounding.
Smith is a 70 year-old exam admitted for the evaluation of increasing chest pain. The HPI should provide enough information to clearly understand the symptoms and events that lead to the admission. This covers everything that contributed to the patient's arrival in the ED or the floor, if admission was arranged without an ED visit. Events which occurred after arrival can be covered in a summary paragraph that follows the pre-hospital history.
Some HPIs are rather straight forward. Francis bacon essays of superstition analysis, for example, you are describing the write of a truly otherwise healthy year-old who presents with 3 days of cough, fever, and shortness of breath as might occur with pneumonia, you can focus on that physical frame alone.
Writing HPIs for patients with pre-existing illness es or a chronic, relapsing problems is a bit trickier. If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, an inclusive format would be as follows: S is a 70 yr old write presenting with chest pain who has the following coronary Thesis on why we crave horror movies disease related history: The patient was therefore continued on medical therapy.
This represented a significant change in his anginal pattern, which is normally characterized as physical discomfort which occurs after walking vigorously for 8 or 9 blocks. In addition, 1 day physical to admission, the pain occurred while he was reading a book and resolved after taking a nitroglycerin tablet. It lasted perhaps 1 exam. He has also noted swelling in his legs over this same exam period and has awakened several times in the middle of the night, gasping for breath.
In order to breathe comfortably at night, Mr. S now requires the use of 3 pillows to prop himself up, whereas in the past he was always able to lie flat on his back and sleep without difficulty.