Class 4 - Physical Exam Flashcards
What is when the clinician evaluates each body system eyes, heart, lungs, skin, etc.) by inspection, palpation, and auscultation?
This is the PE or physical exam.
What does the physical exam help accomplish?
Investigates pt complaints and helps the provider to narrow down or even rule out certain diseases/problems.
What belongs in the PE?
What does NOT belong in the PE?
What the physician saw, heard, felt, and smelled.
Symptoms, medical hx, dx’s, and nothing the physican inspected should NOT and does not belong in the PE.
Note: Make sure to document what is found on the PE using the patient’s anatomy positioning right vs left.
No answer.
Anatomical Terms
What are the terms that describe front and back?
What are the terms that describe “near point of attachment” and “far point of attachment”?
What do the terms medial and lateral mean?
What do the terms superior and inferior mean?
What terms mean the palm of the hand and sole of the foot?
Anterior and posterior
(laceration to the posterior shoulder)
Proximal and distal
(laceration to distal right 5th finger)
Medial means near the midline while lateral means far from the midline
(tenderness to the lateral aspect of the left hand)
Superior means above while inferior means below.
(Laceration inferior to the right eyebrow)
Palmer and plantar
What are the healthy average of vital signs?
BP
PR
RR
Temp
SpO2
120/80
60-100 bpm
12-18
98.6 degrees F
> 96%
What do you call low blood pressure and high blood pressure?
Hypotensive and hypertensive
What do you call a low pulse rate and a high pulse rate?
Bradycardic and tachycardic
What do you call a low respiratory rate and high respiratory rate?
Bradypneic and tachypneic
What do you call a low temp and high temp?
Hypothermic and febrile
Febrile greater than/equal to 100.4 degrees F
What do you call a low SpO2?
Less than or equal to 92% = Hypoxic
For the constitutional exam, what measures are considered normal?
What about Abnormal?
How are these investigated?
Normal
No Acute Distress (NAD)
Well developed, Well nourished
Alert
Mild/Moderate/Severe distress due to pain or respiratory difficulty
Cachectic/Emaciated/Malnourished
These are investigated visually.
For the eye exam, what measures are considered normal?
What about Abnormal?
How are they investigated?
Pupils Equal, Round, Reactive to Light (PERRL) vs. fixed and dilated
- Visual by shining light into pt’s eyes)
Extraocular Movements Intact (EOMI) vs EOM entrapment
No nystagmus (repetitive, uncontrolled movements) vs nystagmus (due to ear issue, alcohol, drugs, or abnormal brain conditions)
- Visual by having pt track finger
Sclerae anicteric vs scleral icterus (liver failure)
Normal conjunctiva (mucous membrane that covers the front of the eye and lines the inside of the eyelids) vs pale conjunctiva (anemia), conjunctival injection (conjunctivitis), discharge or crusting (infection)
- Visual
For the ear exam, what measures are considered normal?
What about abnormal?
How are they investigated?
Tympanic Membranes (TMs) Normal vs some kind of otitis (can be obscured by cerumen aka ear wax)
No canal swelling or tenderness vs swelling or tenderness
Investigated using a otoscope (visual)
For the nose exam, what measures are considered normal?
Normal measures are no discharge, normal nasal mucosa, no active bleeding vs clear/yellow discharge, boggy turbinates/swelling of the nasal muscosa (rhinitis) or site of bleeding identified (epistaxis)
Visual or using otoscope
