Normal physical exam write up

It gets a bit more tricky when writing up patients with pre-existing illness es or a chronic, relapsing problem. The eyes should be able to easily and smoothly follow your finger. This may be the result of relatively minor trauma cough, sneeze, or direct blowa bleeding disorder or idiopathic.

Also ptosis on right right eyelid covers a greater portion of eye than on left. Instillation of dilating drops into one eye will cause anisocoria.

Patterns of innervations are as follows: You will only be able to see a relatively small segment of the retina at any one time.

When infected or otherwise inflamed, this layer can appear quite red, a condition known as conjunctivitis. It is a means of communicating information to all providers who are involved in the care of a particular patient.

Sympathetics also innervate a small muscle in lid, such that sympathetic lesions also cause an element of ptosis. Each eye is tested independently i. In addition, the pupil will not respond well to direct or consensual shined in the opposite eye light. As CN 3, 4 and 6 all travel thru this sinus, they can be adversely affected in the setting of thrombosis.

Then assess whether each pupil constricts appropriately in response to direct and indirect stimulation as follows: This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks.

This will direct you towards the optic disc, the point at which the vessels enter the retina along with the head of the optic nerve. In actual practice, most providers do not document such an inclusive ROS. There is ptosis of the right eye.

At the center of the disc is the optic cup, a distinct circular area from which the blood vessels actually emerge. Viewing the Fundus the retina and associated structures: These vessels are more obvious in the superior and inferior aspects of the retina, with relative sparing of the temporal and medial regions.

When he looks right, his vision is normal. More on Extraocular movements: Testing Extraocular Movements Interpretation: Pupils are 4 mm and briskly reactive to light.

Right CN 3 Palsy - Note: Try to keep both of your eyes open when performing the exam as you might find it quite tiring to continually squint with the non-examining eye. The inferior rectus muscle has become entrapped within the resulting fracture, preventing the left eye from being able to look downward.

For more information about visual field testing, see the following links: She denies associated nausea, vomiting, photophobia, loss of vision, seeing flashing lights or zigzag lines, numbness, weakness, language difficulties, and gait abnormalities.

Dosage and frequency should be noted. It is, however, frequently impossible to directly assess the extent of this damage during physical examination as the affected organs, e. She denies fever, chills, malaise, weight loss, neck stiffness, chest pain, dyspnea, abdominal pain, diarrhea, constipation, urinary symptoms, joint pain, or back pain.

At the same time, she also noted a strange sensation in her right eyelid.

The examiner should be nose to nose with the patient, separated by approximately 8 to 12 inches. The first part of the eye exam is an assessment of acuity. When performing the rest of the exam, make sure that you are in a comfortable position.

Detailed descriptions are generally not required.

Department of Neurology

It helps if the patient has a picture e. Do not ask them to focus on a specific object as this may lead to pupillary constriction. Eye Cross Section Picture Courtesy of Ray Kelly In order to see the fundus in greater detail, you will need to move very close to the patient, analogous to looking through a key hole i.

Practice on every patient that you examine. Speech is clear and fluent with good repetition, comprehension, and naming.


The action which the muscle primarily performs is listed first, followed by secondary and then tertiary actions.home while she was growing up and currently works as an assistant in a veterinarian’s office. She describes her relationship with her parents as warm, and reports that she is Physical Exam: Heart sounds‐RRR, Normal S1 and single S2.

No S3, S4. Patient Centered Medicine 2 F:\\FORMS\ 1 of 5 Revised 1/28/13 DATA BASE SAMPLE: PHYSICAL EXAMINATION. ASM Normal Physical Exam Write-Up study guide by ISMMS_ASM includes 14 questions covering vocabulary, terms and more.

Quizlet flashcards, activities and games help you improve your grades. Example of a Complete History and Physical Write-up Patient Name: Unit No: Normal childbirth 48 years ago 2) Gastrointestinal hemorrhage, see below Physical Exam 1.

Vital Signs: temperature Pulse 96 regular with occasional extra beat, respiration 24, blood. Patient Write-Up. The Initial Visit. Identifying Statement/Chief Complaint. {If no chief complaint, write “for yearly exam” or “school physical Pulses 2+ = normal.

Physical Exam Vital signs: Ht 5’10” Wt lbs HR 72 RR 16 BP /78 Temp Not measured General: Mr. H is a depressed-appearing white male in no acute distress.

Normal physical exam write up
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