Physical examination template
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2]
Introduction to the Physical Examination Page
- The page name should be "(Disease name) physical examination", with only the first letter of the title capitalized.
- Goal:To describe in detail the various aspects of the physical examination with attention to how the disease you are describing may present.
- Remember this section is to describe what characteristics may be found on physical examination, not how to do a physical exam (unless you are including specialized signs, eg Chvostek's sign, in which case you may give a brief description).
- As with all microchapter pages linking to the main page, at the top of the edit box put {{CMG}}, your name template, and the microchapter navigation template you created at the beginning.
- Remember to create links within Wikidoc by placing [[square brackets]] around key words which you want to link to other pages. Make sure you makes your links as specific as possible. For example if a sentence contained the phrase anterior spinal artery syndrome, the link should be to anterior spinal artery syndrome not anterior or artery or syndrome. For more information on how to create links click here.
- Remember to follow the same format and capitalization of letters as outlined in the template below.
- Below you will see examples of what you may describe as part of the physical examination.
Overview
- The overview section should include the disease name in the first sentence.
- The goal is to summarize the physical examination page in several sentences. This section can be the same as the physical examination segment on the overview page.
- To see an example of an overview section on a physical examination page, click here.
Template
- First Sentences:
- Patients with [disease name] usually appear [general appearance]. Physical examination of patients with [disease name] is usually remarkable for [finding 1], [finding 2], and [finding 3].
- Common physical examination findings of [disease name] include
[finding 1], [finding 2], and [finding 3].
- The presence of [finding(s)] on physical examination is diagnostic of [disease].
- The presence of [finding(s)] on physical examination is highly suggestive of [disease].
- Examples:
- Example 1: Patients with shigellosis usually appear lethargic. Physical examination of patients with shigellosis is usually remarkable for high-grade fever and signs of dehydration, such as tachycardia, tachypnea, hypotension, and dry mucus membranes.
Physical Examination
Appearance of the Patient
- This section should give a general description of what a patient with the disease you are describing may look like. You may include a physical description such as obese, thin, cachectic, well appearing, ill appearing, diaphoretic etc.
- For an example of the appearance of a patient section in the physical examination page, click here.
Vitals
Temperature
- A fever is often present
- Hypothermia may be present
Pulse
Rate
- Tachycardia may be present
- Bradycardia may be present
Rhythm
- The pulse is regular
- The pules is irregularly irregular
Strength
- The pulse may be weak
- The pulse may be bounding
- The pulse may be alternating in strength (pulsus alternans)
- A paradoxical pulse may be present
Symmetry
- The pulses may be asymmetric
Blood Pressure
- Hypotension may be present
- Hypertension may be present
- A wide pulse pressure may be present
- A narrow pulse pressure may be present
Respiratory Rate
- Tachypnea may be present
- Bradypnea may be present
- Kussmaul respirations may be present
Skin
- Cyanosis may be present
- Jaundice may be present
- A rash may be present
- Pallor may be present
- Lesions may be present
-
Description (Adapted from Dermatology Atlas)
-
Description (Adapted from Dermatology Atlas)
Head
- Abnormalities of the head/hair may include ___
- There may be evidence of trauma
Eyes
- Icteric sclera may be present
- Nystagmus may be present.
- Extra-ocular movements may be abnormal
- Pupils may not react to light
- Ophthalmoscopic exam may be abnormal with findings of ___
Ears
- Hearing acuity may be reduced
- Weber test may be positive
- Rinne test may be positive
- There may be exudate from the ear canal
- There may be tenderness on movement of the pinnae
Nose
- Nares may be inflamed
- There may be epistaxis
- There may be purulent exudate from the nares
- There may be tenderness to percussion of the sinuses
- The nares may be congested
Throat
- The throat may be erythematous
- There may be exudate in the throat
- There may be petechiae seen in the throat
- There may be tonsillar inflammation
Neck
- Jugular venous pressure may be elevated
- Carotid bruits may be present
- Lymph nodes may be present
- Thyromegaly may be present
- Hepatojugular reflux may be present
Lungs
- Pulmonary edema and rales may be present
- Wheezing may be present
- Consolidation may be present with reduced breath sounds auscultated
- Rales may be present
- Egophony may be present
- Chest movement may be assymetric
Heart
- A heave may be present
- A thrill may be present
- A friction rub may be pressent
Auscultation
- S1
- S2
- S3
- S4
- Gallops
- A systolic murmur best heard at the base may be present
- A systolic murmur best heard at the apex may be present
- A diastolic murmur may be present
Abdomen
- Abdominal distention may be present
- Abdominal tenderness may be present
- Rebound tenderness may be present
- An acute abdomen may be present
- An abdominal mass may be present
- Guarding may be present
- Hepatomegaly may be present
- Splenomegaly may be present
- Genitourinary exam if relevant
Extremities
Neurologic
- Mental status may be altered
- Glasgow coma scale is ___
- Clonus may be present
- Hyperactive reflexes may be present
- There are deficits in cranial nerves ___
References
- References should be cited for the material that you have put on your page. Type in {{reflist|2}}.This will generate your references in small font, in two columns, with links to the original article and abstract.
- For information on how to add references into your page, click here.