week 7 case study

NURS 6512: Physical Examination Reference Sheet NURS 6512 – Advanced Health Assessment & Diagnostic Reasoning

Purpose: To guide students in documenting objective findings only during the physical examination.

REMINDER: PHYSICAL EXAM = OBJECTIVE DATA ONLY This section should include only what you observe, measure, or assess — not what the patient reports. Do NOT include subjective statements or history.

✅ Correct (Objective): “Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi.”

❌ Incorrect (Subjective): “Patient reports shortness of breath and chest tightness.”

GENERAL FORMAT FOR PHYSICAL EXAM DOCUMENTATION • General: Appearance, distress, hygiene, orientation • Skin: Color, temperature, turgor, lesions, rashes • Head: Normocephalic, atraumatic • Eyes: PERRLA, EOMI, conjunctiva clear • Ears: TM intact, no erythema or effusion • Nose: Mucosa pink, septum midline, no discharge • Mouth/Throat: Mucosa moist, no erythema or exudate • Neck: Supple, no lymphadenopathy, thyroid non-enlarged • Cardiac: RRR, no murmurs, rubs, or gallops • Lungs: CTA bilaterally, no wheezes, rales, or rhonchi • Abdomen: Contour, bowel sounds, tenderness, organomegaly • GU: External genitalia, discharge, lesions, CVA tenderness (as indicated) • Musculoskeletal: ROM, strength, gait, deformities, tenderness • Lower Extremities: Edema, pulses, color, warmth, capillary refill, sensation • Neuro: CN II–XII grossly intact, strength and sensation symmetrical

Chief Complaint, Must-Not-Miss Diagnoses, and Systems to Examine Identify high-priority conditions and focus your exam to rule them out.

Chief Complaint Must-Not-Miss Diagnoses Systems to Examine

Cough or Shortness of Breath

Pneumonia, Pulmonary embolism, Myocardial infarction, Heart failure, Pneumothorax

Respiratory, Cardiac, ENT, Skin (cyanosis), Lower Extremities (edema/DVT signs)

Abdominal Pain Appendicitis, Bowel obstruction, Perforated

Abdomen, GU, Cardiac, Respiratory, Skin

ulcer, Ectopic pregnancy, Cholecystitis, Pancreatitis

(jaundice), Neuro (pain localization)

Headache Subarachnoid hemorrhage, Meningitis, Temporal arteritis, Intracranial mass, Hypertensive emergency, CVA (stroke)

Neuro, HEENT, Neck, Eyes (fundoscopic), Cardiac (BP), Skin (rash/meningitis)

Back Pain Cauda equina syndrome, Epidural abscess, Spinal fracture, Pyelonephritis, Abdominal aortic aneurysm (AAA)

Musculoskeletal, Neuro, Abdomen, GU (CVA tenderness), Skin (infection)

UTI Symptoms Pyelonephritis, Urosepsis, Pregnancy, Obstructive uropathy

Abdomen, GU, CVA tenderness, Skin (fever signs), Neuro (confusion in elderly)

Sore Throat Peritonsillar abscess, Epiglottitis, Mononucleosis, Streptococcal pharyngitis

HEENT, Lymphatic, Neck, Cardiac, Respiratory (airway), Skin (rash/scarlatina)

Rash Cellulitis, Meningococcemia, Stevens-Johnson syndrome, Drug reaction, Anaphylaxis

Skin, Lymphatic, HEENT (mucosal lesions), Respiratory (distress), Cardiac (shock signs)

Extremity/Joint Pain DVT, Septic joint, Fracture, Cellulitis, Compartment syndrome

Musculoskeletal, Neuro, Lower Extremities (pulses, edema, warmth, sensation), Skin

DOCUMENTATION TIP • Use head-to-toe format only for comprehensive exams (annuals, new patient, baseline). • Use focused format for problem-based visits. • Objective findings should align with your assessment and must-not-miss differential diagnoses.