How to Read Physical Exam Reports

Physical exam reports present a paper snapshot of the patient's health at the time of the exam.

Physical exam reports are completed by the physician and patient during annual or biannual physical exams. These typically include patient medical history, current ailments, vaccinations, blood work results and the doctor's findings during the physical examination. They also include current patient status, usually weight, height, medications or supplements used and any chronic conditions such as GERD (acid reflux) or psychological conditions like major depressive disorder. Office information may also be found on physical exam reports such as patient insurance information, change of address, contact information and emergency contacts.

Things You'll Need

• Physical exam report

Instructions

1. Start at the top of the physical exam report, which usually contains the patient's name, birth date and age. It may also include the patient's address and contact information.

2. Find the physical characteristics of the patient, which are usually also near the top of the physical exam report, and typically include height, weight, blood pressure, pulse, temperature and, for women, the date of their last menstrual cycle (LMP). Physical exams may note whether the patient wears corrective lenses as well, but vision is usually not tested by the physician.

3. Closely read the patient history, which usually comprises a list of health conditions such as high blood pressure, diabetes, cancer and migraines, among others, where the patient checks "yes" for the condition affecting the patient, "no" if the condition does not affect the patient or "family" if the condition affects someone in the patient's bloodlines. You want to be sure the history is accurate and all important health conditions are included.

4. Ask the physician to explain any aspects of the physical exam you don't understand or want to know more about. The physician works through a checklist as he completes the physical exam. This list is a general reminder to check eyes, throat, ears, abdomen, breathing, reflexes and other aspects of the patient's health. As the physician examines the patient, he will check off list areas and make comments regarding normal and abnormal findings. Abnormal findings usually result in a patient referral to a specialist such as for an MRI or X-ray.

5. Ask the physician to explain the lab results on a physical exam report. Lab results will present the item analyzed, such as blood or urine, and when blood work is conducted, the different parts of the blood assessed are listed. There will be two values for each lab work item. The first value is usually the patient's results followed by a second value presented as a numerical range; this range is the normal pattern for the item tested. It is provided to give an idea of where the patient falls. If the patient is below the lowest number in the range, her results are abnormally low, while if the result is above the highest number in the range, the patient's value is abnormally high. This is particularly relevant with blood sugar, sodium, white blood cells (leukocytes) in blood and also proteins or blood in urine that may signal a bladder infection.

References

• Medical Examination Report for Commercial Driver Fitness Determination
• Physical Examination Report Form
• North Carolina Division of Motor Vehicles: Physical Examination Report
• Texas Department of Assistive and Rehabilitative Services - Division of Rehabilitation Services: General Physical Examination Report