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Physical examination

Physical examination
Intervention
Reeve 978.jpg
An examination room in Washington, DC, during the first World War
ICD-9-CM 89.7
MeSH D010808
MedlinePlus 002274
[]

A physical examination, medical examination, or clinical examination (more popularly known as a check-up) is the process by which a medical professional investigates the body of a patient for signs of disease. It generally follows the taking of the medical history—an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

A Cochrane Collaboration meta-study found that routine annual physicals did not measurably reduce the risk of illness or death, and conversely, could lead to over-diagnosis and over-treatment. The authors concluded that routine physicals were unlikely to do more good than harm.

Routine physicals are physical examinations performed on asymptomatic patients for medical screening purposes. These are normally performed by a pediatrician, family practice physician, physician assistant, a certified nurse practitioner or other primary care provider. This routine physical exam usually includes the HEENT evaluation. Nursing professionals such as Registered Nurse, Licensed Practical Nurses develop a baseline assessment to identify normal versus abnormal findings. These are reported to the primary care provider.


Section Sample text Comments
General "Patient in NAD. VS: WNL" May be split on two lines. "WNL" = "within normal limits"
HEENT: "NC/AT. PERRLA, EOMI. No cervical LAD, no thyromegaly, no bruit, no pallor, fundus WNL, oropharynx WNL, tympanic membrane WNL, neck supple" "Neck" is sometimes split out from "Head". "Good dentition" may be noted.
Resp or "Chest" "Nontender, CTA bilat" Chest expansion test, normal breathing with little effort, absence of wheezing, rhonchi and crackles. More detailed examinations can include rales, rhonchi, wheezing ("no r/r/w"), and rubs. Other phrases may include "no cyanosis or clubbing" (if section is labeled "Resp" and not "Chest"), "fremitus WNL", and "no dullnes to percussion".
CV or "Heart" "+S1, +S2, RRR, no m/r/g" If "CV" is used instead of "heart", peripheral pulses are sometimes included in this section (otherwise, they may be in the extremities section)
Abd "Soft, nontender, nondistended, absence of pain, no hepatosplenomegaly, NBS" If lower back pain is involved, then the "Back" may become a primary section. Costovertebral angle tenderness may be included in the abdominal section if there is no back section. More detailed examinations may report "+psoas sign, +Rovsing's sign, +obturator sign". If tenderness was present, it might be reported as "Direct and rebound RLQ tenderness". "NBS" stands for "normal bowel sounds"; alternatives might include "hypoactive BS" or "hyperactive BS".
Ext "No clubbing, cyanosis, edema" Checking the fingers for clubbing and cyanosis is sometimes considered part of the pulmonary exam, because it closely involves oxygenation. Examinations of the knee may involve the McMurray test, Lachman test, and drawer test.
Neuro "A&Ox3, CN II-XII grossly intact, Sensation intact in all four extremities (dull and sharp), DTR 2+ bilat, Romberg negative, cerebellar reflexes WNL, normal gait" Sensation may be expanded to include dull, sharp, vibration, temperature, and position sense. A mental status exam may be reported at the beginning of the neurologic exam, or under a distinct "Psych" section.

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Wikipedia

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