Click here to receive the latest news!
free-template.co
free-template.co

Stay Healthy With This Normal Physical Exam Template

Stay Healthy With This Normal Physical Exam Template

Adults should undergo a routine physical exam once a year to test for diseases, identify the risks of potential future medical problems, update vaccines, and promote a healthy lifestyle, according to doctors.

Joan Cornish
Last updated: Nov 17, 2021 | Nov 05, 2021

Table of Contents

Adults should undergo a routine physical exam once a year to test for diseases, identify the risks of potential future medical problems, update vaccines, and promote a healthy lifestyle, according to doctors. The vast majority of patients seek medical assistance only when they are sick. Maintaining a relationship with your doctor, even if you are feeling fine, will allow us to identify any concerns, such as high blood pressure, early and treat them before they become more serious.

During this exam, your doctor will go through your family history and medical history with you, as well as extensively evaluate the following for any atypical signs/symptoms that could suggest an imminent medical problem:

  • Skin
  • Entire head
  • Eyes
  • Ears
  • Nose and sinuses
  • Mouth and pharynx
  • Neck
  • Back
  • Breast and armpits
  • Heart
  • Lungs
  • Abdomen
  • Rectum and anus
  • Reproductive Organs
  • Legs
  • Blood vessels
  • Spine

They will most typically use a normal physical exam template while assessing you, which you can find also in this article.

What Are Some Normal Physical Examination Findings?

Cheat Sheet: Normal Physical Exam Template

Two critical functions are served by documentation. It keeps you out of jail for starters. Okay, so incarceration isn't a realistic option, but there are lots of instances in which your behavior as a healthcare professional could be questioned. And in the realm of medicine, if you don't write it down, it didn't happen. In the event that another physician, patient, or other party does not agree with your actions, documenting your findings on a physical exam as well as the reasoning for your plan of care helps as a defense.

Secondly, documentation aids in the continuity of care of patients. How inconvenient is it to be expected to pick up where another provider left off, only to discover that they left little more than two lines of handwritten chicken-scratch scrawled across the chart regarding the patient's situation? Don't let yourself become that person. Documenting your findings and treatment plan for the patient enables other healthcare practitioners to continue caring for the individual in your absence. Alternatively, it permits others to give care alongside yours without interfering with your part of the care plan. Document exam findings and your next steps with the patient to keep everyone informed.

A physical exam isn't always documented the way you learned it to be in school, and it is crucial to remember that. Most providers, under pressure to be more efficient, condense physical exam documentation to only the essentials. There's a narrow line to be drawn between spending too much time charting and documenting too little. Because the amount you're paid for each patient visit is determined by your documentation, cutting corners might have a direct impact on your bank account. With practice, you'll be able to find a balance between how much and how little information to include in your chart.

A thorough examination and provision of documentation for each individual body system are not required in the vast majority of cases. This template will provide a detailed description of each body system for the purposes of providing a general overview. In practice, you should focus on systems that are relevant to the patient's history and presentation.

Finally (and this is a caution), this page does not purport to be an exhaustive resource for documentation. It's designed to be a useful tool that can be used in a clinical context. You may need to record discoveries not covered in this sample write-up with particular patients.

General

General physical exam
  • Well-built and well-fed, the subject appears to be of a specific age.
  • Constantly aware of time, place, person, and situation.
  • Both recent and distant memory are preserved. Excellent perception and cognitive function. There are no signs of aphasia, dysarthria, or hoarseness.
  • Normal gait and station, negative Rhomberg.
  • Warm, dry, and turgorous skin. There is no discoloration, bleeding, rash, or other lesions. Hair maintains its natural texture and dispersion. There are no alterations to the nails.

Head

head physical exam
  • Normocephalic, no scalp lesions.
  • Face sensation is unaffected. There is no facial asymmetry, and all facial expression muscles are intact.
  • Ears and nose that are free of deformity, outward pain, or discharge
  • By rough testing, hearing is found to be intact bilaterally (or: to whisper)
  • Conjunctivae pink, sclerae white, no jaundice. There is no en- or exophthalmos, nor is there lid ptosis. External ocular motions (EOMs) are complete (or intact), with no strabismus or nystagmus. Pupils equalize, respond to light, and accommodate (PERRLA). Visual fields remain intact in the face of conflict.
  • Lips are normal color and free of lesions in the mouth and throat. Teeth are present, and dental hygiene is satisfactory. Pink gums and mucous membranes without bleeding, lesions, or inflammation Tongue size and papillation are typical, with a midline protrusion. Tonsils aren't swollen (or: absent).
  • Palate raises symmetrically, gag remaining intact.

Chest & Back

chest & back physical exam
  • There is no aberrant spine curvature. There is no muscle spasm or discomfort, and there is full range of motion.
  • Female breasts are symmetrical and normal in size, with no dimpling, lumps, soreness, or skin abnormalities. There is no nipple deformity or discharge.
  • There are no swollen axillary lymph nodes.

Cardiovascular

cardiovascular physical exam

There are no lifts, heaves, or thrills on the outside of the chest. PMI is palpated in the 5th intercostal space at the midclavicular line and is not visible. The rate and rhythm of your heart are normal. There are no murmurs, gallops, or rubs audible. S1 and S2 are audible and of average intensity.

Abdomen

abdomen physical exam

Without scars, a scaphoid. There is no unusual tympany. No bruits, just normal bowel sounds. Deep and superficial palpation without organomegaly or masses; no direct or rebound discomfort, rigidity, or guarding. The liver margin is soft (or not perceptible), and the liver span is 10 cm. The spleen is normal in size (or not palpable), and the kidneys are not palpable.

Extremities

extremities physical exam
  • There is no asymmetry or muscular atrophy. All joints have full range of motion (ROM).
  • Skin temperature is normal. There is no edema or superficial varicosities.
  • The lymph nodes in the groin are not swollen.
  • There are no bruits over the femoral artery, and all distal pulses (or: femoral, popliteal, PT, and DP pulses) are intact, full, and equal.

How Do You Get Ready For A Physical Examination?

How Do You Get Ready For A Physical Examination

Make an appointment with your primary care physician at a time that is convenient for you. You can also request a list of practitioners in your area from your health insurance company. A little planning ahead of time for your physical examination will help you make the most of your time with your primary care physician. You should make a list of the following important information:

  • A list of your current prescriptions, including herbal, vitamin, and mineral supplements, as well as over-the-counter medications
  • Make a list of any recent symptoms or pains you've had.
  • A record of your most recent or pertinent laboratory tests
  • A detailed account of your medical and surgical history
  • A list of specialized doctors you've seen this year, as well as documentation of medical records from them
  • Any implanted device information, such as a pacemaker or defibrillator. Keep a copy of your device's card as well as the doctor's suggestions.
  • If you have any allergies or have had a drug response, please let us know.
  • Any other concerns you have?
  • Avoid wearing jewelry, make-up, or any other fashion item that could interfere with the inspection procedure by dressing in comfortable attire.

Conclusion

As part of healthcare, physical examinations are a must. In order to assess a patient's overall health, identify any potential medical disorders, and keep tabs on certain symptoms, doctors and nurses employ these tools.

It's common for doctors to urge more testing when they detect an underlying health problem.

In most cases, they'll try to make the process as easy and stress-free as possible. Concerned patients should talk to their doctor before scheduling a physical checkup.

Joan Cornish | Software Engineer: From banking industry to running my own business. Previously worked with Wordpress clients, but recently built our in-house CMS with 100 Mobile Google Page Speed. Free websites for Charity or Non For Profit. Contact us to learn more.

Related

Reliable Change Management Plan Template To Use This 2021

Changes in a company, regardless of their scope and nature, can be a make-or-break episode, and a change management plan template can aid in making changes successful. One particular maxim from Heraclitus, who lived around 500 BC, according to the Stanford Encyclopedia of Philosophy, still rings true this 21st century. To paraphrase what the Greek philosopher once said, change remains to be the only constant thing in this world.

Download Free Chill Wallpapers HD For Your iPhone & PC

Chill wallpaper is ideal for your laptop, particularly if your job has gotten a little too stressful for you to cope with. Waves may be felt even if you are not on vacation or in close proximity to the ocean.

Top Websites To Get 4K Cool Lock Screen Wallpapers Free

Smartphone backgrounds may represent your personality at times. It will be the first thing you see consciously (subconsciously) when you activate the smartphone, whether you want to remind yourself of a motivating quotation or simply have your own picture from a nice area.

Cute Wallpapers For Teens On Windows And MAC

Make a statement about your faith with these new Cute wallpapers for teens! Using one of these as your phone's lock screen is a great way to remind yourself to pray or to read an inspirational quote.Find a Wallpaper that Symbolizes Your Personality!

Go Get The Best Design App For Phones

It won’t be surprising for those graphic artists and similar designers who find themselves frequently moving from one place to another to use at least one mobile design app. It will always come handy for people on the go, especially when a deadline looms.

Donation Request Letter Template 2021: Top 4 Easy Guides And Effective Tips You Must Apply In Writing!

Donation letters are one of the most efficient ways to get in touch with your donors and ask for a donation. However, merely sending the same request to your whole supporter network and asking them to donate isn't enough.

Free Designs For Commercial Use You Don’t Want To Miss

If you run out of ideas, either as a graphic designer or as someone running a website for your small business, get free designs from several websites at any given time. It’s not also only a matter of getting inspiration or a fresh perspective, but chances are, you might be working on a tight budget for designs.

Components Of A Real Estate Contract Template You Must Never Miss

It could be surmised that real estate professionals know the basics of a real estate contract template like the back of their hand. After all, no transaction occurs without the said contract involved.

Top 5 Effective Guides And Tips For Making Residential Lease Agreement Template 2021

A lease agreement is a legally binding contract between a landlord and a tenant that spells out the circumstances under which the tenant can rent property from the landlord. The standard items in a lease include the amount of rent, the length of the lease, who is responsible for certain maintenance problems, and the penalties that can be levied if the terms are not followed.

Free Writing Template For Kids This 2021 That Will Enhance Their Cognitive Skills

It is important to emphasize that writing with children involves primarily the facilitation of their written expression through the developmental progression from mark marking, scribbling, and drawing,

Click here to receive the latest news!

© Copyright 2022 free-template.co All Rights Reserved

Terms & Privacy | admin@free-template.co