course 4 soap Flashcards
What is the difference between ROS and PE?
ROS - subjective, generally filled out by patient. PE - hands on findings from the provider
What are the body systems the provider checks in the PE
Constitutional, Eyes, ENT, Neck, CV, Respiratory, GI, musculoskeletal, Skin, neurological, psychological
Brudzinski’s sign, which system is evaluated and what is it
Neck, stiffness associated with meningitis
Pulse evaluation is recorded how? Normal is what
scale from 0-4+. Normal is 2+
CTAB which system is evaluated and what is it
respiratory, clear to auscultation bilaterally
peritoneal signs, what are they, what system
guarding, rebound, rigidity, GI system
Murphy’s sign is what and suggests what
point tenderness in RUQ, cholecystitis
McBurney’s sign is what and suggests what
point tenderness in RLQ, appendicitis
CSMT
circulation, sensory, motor, tendon, musculoskeletal
Oriented x4
identification of place person time situation
motor strength is measured how? what system
scale from 5/5, 5 being normal. pronator drift, neurological
Reflexes measured how and with what? What system
0-4+ scale, 2+ normal, measured with hammer, neurological
Objective information includes what?
Vitals, PE, Orders/Results
Vitals are what?
BP, HR, PR, RR, SaO2
Normal pulse rate
60-100 bpm
