By Li G.
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Be alert to special situations that may occur during a patient encounter. Finally, you should remain alert to special situations that may not unfold as would an ordinary physical exam. When you enter the exam room, for example, the patient may hand you an insurance form requesting that only certain systems be examined. In such cases, the patient will usually tell you that you do not need to take a history. Should this occur, simply introduce yourself, proceed to examine the systems listed, and then leave the room.
No murmurs, rubs, or gallops. ● Abdomen: ࠗ Soft, nontender, nondistended, BS ᮍ, no hepatosplenomegaly. ● Extremities: ࠗ No clubbing, cyanosis, or edema. ● Mental Status Exam: ࠗ Patient speaks slowly. ࠗ No hostile behavior toward the interviewer. ࠗ Blunt affect with poor eye contact. ࠗ Inattentive to interviewer. ࠗ 3/3 registration, 3/3 recall at 3 times. ࠗ Distant memories are impaired. ࠗ Oriented to person, date, and place. ࠗ Completed three-step command. ࠗ Right-handed. ࠗ 1/5 on serial 7s. ࠗ Poor judgment.
Are the physical exam results complete? F i g u r e 2 - 6 . Examples of How to Document Physical Exam Findings HEENT: ࠗ Head: Atraumatic, normocephalic. ࠗ Eyes: EOMI, PERRLA, normal eye fundus. ࠗ Nose: No nasal congestion. ࠗ Throat: No tonsillar erythema, exudates, or enlargement. ࠗ Mouth: Moist mucous membranes, good dentition, no lesions. ● Neck: Supple, no JVD, normal thyroid, no cervical LAD. ● Nervous System: ࠗ Mental status: Alert and oriented x 3, good concentration. ࠗ Cranial nerves II–XII grossly intact.
[Article] A sample size adjustment procedure for clinical trials based on conditional power by Li G.