This is what is observed by you the healthcare provider. It includes tests, measurements, observations, etc. Use the pneumonic listed below for a crutch. Keep in mind that not all of these areas will be done. It is dependant on the chief complaint and the subjective history as to what exam tests below that are done. To help you remember what to do when performing an exam, use the following pneumonic - IPPIRONEL.
I: In this section, include inspection of the area of the chief complaint and describe anything abnormal.
P: Palpate the area and describe what you find -- hardness, softness, pain, spasm, etc.
P: Percussion to the area listening for abnormalities or reproduction of the pain.
I: Use any necessary instrumentation like ear, nose and throat diagnostic kit, etc.
R: Do active, passive and resisted ranges of motion in all planes.
O: Conduct necessary orthopedic tests pertaining to the area of the chief complaint. For example: Straight Leg Raise (SLR), Kemps Test, etc.
N: Neurological evaluation to include cranial nerves, dermatomes, light touch, sharp vs. dull, temperature, position sense, graphism, etc. and reflexes. If needed do girth measurements of the extremities.
E: E stands for x-ray, MRI, CT scan, Bone Scan, etc. Include the name of the test, view taken, date done, and the interpretation. Include the radiologist name who interpreted the study.
L: Laboratory test ordered. Include the pertinent results to the patient care.
Copyright 2010 by Dr. Kevin McNamee, DC, LAc. Please do not duplicate in any manner.