Learning to Interpret Physical Exam Findings Background
A physical examination 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.
Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities.
A physical examination usually includes: Inspection (looking at the body), Palpation (feeling the body with fingers or hands), Auscultation (listening to sounds), and Percussion (producing sounds, usually by tapping on specific areas of the body).
With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms.
Typical Documentation Format of a Physical Exam
General Appearance (GEN)
Vitals (VITALS)
Temperature (T), Blood Pressure (BP), Pulse (HR), Respiration rate (RR), and Pulse oximetry (SPO2)
Head, Eye, Ear, Nose and Throat (HEENT)
Neck (NECK)
Cardiovascular (CV)
Lungs (LUNGS)
Abdomen (ABD)
Extremities (EXT)
Neurological (NEURO)
Psychiatric (PSYCH)
Skin (SKIN)
Genitourinary (GU)
Rectal (RECTAL)
Instructions
For each term/abbreviation in a group, select the section of the physical exam it would most likely be used.
When you have finished selecting for all five terms/abbreviations click "Check Answers."
If all grade boxes change from "Ungraded" to "CORRECT" you may proceed to the next group.
If any grade box changes to "WRONG" then that entry must be corrected before proceeding. After making all necessary changes, click "Check Answers" as before.
When all of the answers for all 6 groups display "CORRECT" you may print a certificate of completion by clicking the button at the top of the page.