Reporting the exam
The exam is reported in a standard and predictable way, so your reader or listener can anticipate and interpret your findings. To maximize efficiency and patient comfort, a complete exam is usually PERFORMED from head-to-toe. However, it is REPORTED by organ system.
For example, the carotid pulses are checked as the neck is examined and the foot pulses are checked at the end of the exam, but these are both reported with the cardiovascular exam.
In Immersion, you will learn to report typical physical exam findings. During your blocks, you will learn much more about pathophysiology and abnormal findings. We will return to reporting the exam in each advanced physical exam workshop.
Standard vocabulary and reference points
The reference points and terms you have learned in Anatomy are also used to describe physical exam findings. These are based on the anatomic position: standing and facing forward, with the palms facing forward. Here’s a refresher.
| Anatomic Term | Definition |
|---|---|
| Anterior or ventral | Near the front |
| Posterior or dorsal | Near the back |
| Superior or cranial | Upward, or near the head |
| Inferior or caudal | Downward, or near the feet |
| Medial | Toward the mid-line |
| Lateral | Away from the mid-line |
| Proximal | Closer to a reference point (often the trunk) |
| Distal | Farther from a reference point (often the trunk) |
| Sagittal plane | Divides the body into right and left parts |
| Coronal plane | Divides the body into front and back parts |
| Transverse | Divides the body into upper and lower parts (or cross-sectional plane) |
Reporting typical findings
As you learn the exam in Immersion, you should also learn how to describe the usual findings in a healthy person. The sample document below is for a healthy person with no unusual or abnormal findings.