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Physical Examination
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"General (Complete) Physical"
The examination process is certainly the most important part of a patient work up. A complete physical examination includes four types of evaluation:
- visual – what is seen
- auditory or aural – what is heard
- olfactory – what is sensed by the nose
- tactile – what is felt
The body regions are as follows:
GENERAL: How the patient appears to the examiner physically and mentally
VITAL SIGNS: Temperature, pulse, respirations, blood pressure, height and weight
SKIN: Turgor, color, tone, etc.
HEENT: Short for head, eyes, ears, nose and throat
NECK: Pulses, thyroid are checked
CHEST: Includes heart (cardiac), lungs, breasts
ABDOMEN: Includes exam of the palpable internal organs
GENITALIA: Male/Female anatomy appearance
RECTAL: Tone, hemorrhoids, checked for blood (melena)
EXTREMITIES: Arms, hands, legs, feet
NEUROLOGIC: Neurologic examination/testing
IMPRESSION: Main heading. What the examiner thinks is wrong with the patient. Sometimes this appears as “problem” in a “problem-oriented” record, listing each problem numerically and discussing it in the order presented.
FOR MORE DEFINITIVE INDIVIDUAL REGIONAL EXAMINATIONS (by specialty or problem)
Abdominal examination
Chest examination
Heart examination
Pulse (Pulses) Exam/Testing
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