Class 4 Flashcards
What is included in the objective portion of the chart?
healthcare provider’s observations
diagnostic tests
vital signs
What are elements of the PE?
inspection (looking)
palpation (feeling)
auscultation (listening)
What is the only thing that belongs in the PE portion of the chart?
only things that the physician saw, heard, felt or smelled
should not include any subjective information or PMHx
Front
anterior
Back
posterior
near point of attachment
proximal
far from point of attachment
distal
near midline
midal
far from midline
lateral
above
superior
below
inferior
one area
focal
widespread
diffuse
palm of hand
palmar
sole of foot
plantar
surface
superficial
What is the physical exam grouped by?
body systems
What are the 5 vital signs?
BP, HR (pulse rate), RR, T, SaO2 (SpO2)
What are abnormal pulse rates?
Bradycardic (below 60 bpm)
Tachycardic (above 100 bpm)
What are abnormal RR?
Bradypneic (below 12 bpm)
Tachypneic (above 18 bpm)
Constitutional meanig
the general appearance of patient
these findings are typically appreciated without touching the patient
What would contradict “alert” ?
somnolent, obtunded, unresponsive
What would contradict “well developed, well nourished” ?
Cachectic, emaciated, malnourished
What is being invesitgated in constitutional part of PE?
distress level, general appearance, smell
What is being investigated in eye portion of PE?
pupils, sclera, conjunctiva, movement
What is being investigated in ENT portion of PE?
outer ear, inner ear, nares, dentition, oropharnyx
How do you examine the inner ear?
use an ophthalmoscope
What is sclera?
the white of eye
What is being investigated in neck portion of PE?
lympth nodes, thyroid, carotid artery, jugular vein, vertebrae, muscles
What is being investigated in cardiovascular portion of PE?
rate and rhythmn (assessed with stethoscope)
pulses
What is being assessed in pulmonary portion of the exam?
Respiratory distress, breath sounds
What is being investigated in GI portion of PE?
Tenderness, enlarged organs, bowel sounds
What is being assessed in GU portion of PE?
masses, skin or mucosal findings, bleeding
What is being assessed in musculoskeletal portion of PE?
bones or muscle tenderness, deformity, range of motionn
What is being assessed in skin portion of the PE?
rashes, infections, trauma
What is being assessed in lymphatic portion of PE?
lymph node