Using a friend, family member, or colleague, perform a neurovascular (include all cranial nerves),
musculoskeletal, and cardiopulmonary (includes the heart, lungs, and peripheral vasculature)
exam.Document the physical examination findings in the SOAP note format.
Even though your patient may have abnormal findings, you must document the expected normal exam
findings for the system. If you would like to include the abnormal findings they should be noted in
parenthesis next to the normal expected findings. The complete subjective and objective sections must
be included. You may include the assessment and plan portion of the SOAP note, but these sections will
not be graded.
You should devise a chief complaint so that you may document the OLDCART (HPI) data. You must
use the chief complaint of headache, back pain, and cough. You should also focus the ROS based on
the patient’s chief complaint and the body systems being examined. Refer to the SOAP Note Format
document in Course Resources as necessary. This will be the same format that faculty will follow during
the immersion weekend.
* There are videos of the exams to be performed at immersion in Modules → Introduction and
Resources→ Immersion section. Also the immersion evaluation forms are located in the Course
Resources section. They should be reviewed and practiced often.
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