Complete Solutions
abdominal normal findings Correct Answer - normal
appearance
- non-tender to palpation
- abdomen is soft
- normoactive bowel sounds
- no CVA tenderness on palpation
add this section if the provider palpates the patient's abdomen
alert and oriented abnormal findings Correct Answer - appears
drowsy or somnolent
- disoriented to person, place, situation, or time
- unresponsive to verbal or painful stimuli
- does not follow commands
atraumtic, normocephalic abnormal findings Correct Answer -
hematoma to scalp
- ecchymosis to bridge of nose
- laceration to right eyebrow
awake and alert abnormal findings Correct Answer - appears
drowsy or somnolent
- unresponsive to verbal or painful stimuli
cardiac normal findings Correct Answer - heart is normal to
auscultation
- regular rate and rhythm
,- peripheral pulses are 2+ and symmetric
- no edema
chest/lungs normal findings Correct Answer - normal and
symmetrical appearing chest
- no wheezing, rales, or rhonchi
- normal to palpation
Constitutional General Normal findings Correct Answer - no
acute distress (NAD)
- Well nourished, well developed
- awake and alert
- general appearance is normal
cranial nerves intact bilaterally abnormal findings Correct
Answer - right/left sided facial droop
- gaze deviation
- asymmetric eyebrow raise
- asymmetric smile
- unequal shoulder shrug
- unequal pupils
dorsiflexion and plantar flexion intact abnormal findings
Correct Answer - decreased dorsiflexion
- decreased plantar flexion
DP and PT pulses are 2+ and symmetric Correct Answer
decreased DP and/or PT pulses
DP and PT pulses are 2+ and symmetric abnormal findings
Correct Answer decreased DP and/or PT pulses
, Ears normal findings Correct Answer - normal TMs bilaterally
- normal external canals bilaterally
- normal pinna
EOMI abnormal findings Correct Answer - ocular
deviation/strabismus
- nystagus
a patient may have nystagmus and still have EOMI
eyelids and lashes appear normal Correct Answer - swelling of
eyelid
- ptosis
- stye
- chalazion
- hordeolum
eyes normal findings Correct Answer - PERRL
- EOMI
- Normal conjunctive
- normal sclera
- normal cornea
- eyelids and lashes appear normal
face is otherwise normal abnormal findings Correct Answer -
sinus tenderness; maxillary and/or frontal
- tenderness to nasal bridge
- TMJ tenderness
- laceration, abrasions, or ecchymosis to face