ED 4 Flashcards
Physical Exam
When clinician evaluates each body system by inspection, palpatations, and ausculiation
Why is physical exam important?
It allows the provider to narrow down the cause
What’s the scribes responsability?
Documenting the physical exam as the provider performs it.
Do you need to be taking notes even if the doctor isn’t talking to you?
Yes!
What belongs in the physical exam?
What the provider saw, heard, felt, and smelled
What doesn’t belong in the physical exam?
Symptoms, Medical History, Diagnoses, Not inspected
RUE
Right Upper Extremitiy
RLE
Right Lower Extremity
LUE
Left Upper Extremity
LLE
Left Lower Extremity
Anterior
Front
Posterior
Back
Medial
Near midline
Superior
Above
Focal
One area
Palmar
Palm of hand
Superficial
Closer to exterior
Deep
Further from exterior
Proximal
Near point of attachment
Distal
Far point of attachment
Lateral
Far from midline
Inferior
Below
Diffuse
Widespread
Plantar
Sole of foot
Constitutional
NAD, well developed/well nourished, alert
Abnormal Constitutional
Mild/Moderate/Severe Distress due to pain or respiratory difficulty, Cachectic/Emaciated/Malnourished, Somnolent/Obtunded/Unresponsive
Eyes
PERRL, EDMI, No nystagmus, scleral anicteric, normal conjuctiva
Abnormal Eyes
Fixed and Dilated, EOM entrapment, Nystagmus, Pale conjunctiva/Conjunctival injection, Discharge or crusting
Ears
TMs Normal, No canal swelling or tenderness
Abnormal Ears
TM erythema/effusion/bulging/dullness/obscured by cerumen, Canal swelling or tenderness
Nose
No discharge, Normal nasal mucosa, no active bleeding
Abnormal Nose
Clear or yellow discharge, boggy turbinates/swelling of nasal mucosa, site of bleeding identified
Throat and Mouth
Moist mucous membrane, oropharynx normal, normal dentition
Abnormal Throat and Mouth
Dry mucous membranes, pharyngeal erythmea/exudates/tonsillar hypertrophy/tonsillar asymmetry/uvular shift, edentulous/dental caries/gum tenderness or edema
Neck
Normal range of motion, Supple/No meningisums, no tenderness, no cervical lymphadeneopathy, no JVD, no carotid bruit
Abnormal Neck
Limited range of motion, nuchal ridgity/meningismus, vertibral point vs. paraspinal tenderness, anterior and/or posterior cervical lymphadenopathy, JVD, carotid bruit
Cardiovascular
Regular rate, regular rhythm, heart sounds normal
Abnormal Cardiovascular
Tachycardia/Bradycardia, Irregularly irregular rhythm, murmurs/rubs/gallops/extrasytoles
Pulses
2+ (easily palpable/normal), capillary refill less than 2 seconds
Abnormal Pulses
0/1+/3+/4+, delayed capillary refill
Respiratory
No respiratory distress, clear to auscultation bilaterally
Abnormal Respiratory
Mild/Moderate/Severe Respiratory Distress, Tachypnea, accessory muscle use, pursed lip breathing, diminished breath sounds, wheezes, rales, rhonchi
Gastrointestinal
Soft, nontender, negative Murphy’s sign, negative McBurney’s point tenderness, normal bowel sounds, no organomeagly
Abnormal Gastrointestinal
Rigidity, Mid/Mod/Severe Tenderness, guarding, rebound, rigidity, positive Murphy’s sign, positive McBurney’s point tenderness, absent/hypoactive/hyperactive bowel sound, hepatomegaly, spenomegaly
Genitourinary
Musculoskeletal
Nontender T-Spine and L-Spine, no CVA tenderness, no tenderness to the extremities, no edema, normal ROM, Distal CMST
Abnormal Musculoskeletal
Paraspinal tenderness, vertibral point tenderness, costovertebral angle tenderness, bony tenderness, soft tissue tenderness, calf tenderness, edema, limited range of motion secondary to pain, pulse/sensory/motor deficits, tendon laxity
Skin
Warm, dry, normal color, no rashes, no induration, no fluctuance, no purulent drainage
Abnormal Skin
Cool/hot to touch, diaphoretic, jaundice/cyanotic/pallor, Urticaria/wheals/maculopapular rash, Petechiae, induration, fluctuance, purulent drainage
Lymphatic
Neurological
Alert, oriented x 4, speech, cranial nerves 2-12 intact, motor strength 5/5 and symmetric, sensation intact, reflexes 2+ and symmetric, normal gait, no nystagmus, normal finger to nose / heel to shin, negative romberg’s
Psychological
Average BP
120/80
Average Pulse Rate
60-100 bpm
Average Respiratory Rate
12-18
Temperature
98.6 F
SpO2
> 96%
Hypotensive
Low BP
Hypertensive
High BP
Bradycardic
Low pulse rate
Tachycardic
High pulse rate
Bradypneic
Low respiratory rate
Tachypneic
High respiratory rate
Hypothermic
Low temperature
Febrile
High temperature
Hypoxic
Low SpO2