OP 4: Objective Flashcards
Objective Information
Factual information that comes directly from a healthcare providers observations and diagnostic tests.
What are the three components to the objective evaluation?
- Vital Signs
- Physical Exam
- Orders/Results
Physical Exam
When the clinician evaluates each body system (eyes, heart, lungs, skin, etc.) by inspection, palpation, and auscultation. It is important because the physical exam investigates patient complaints and helps the provider to narrow down or even rule out certain diseases/problems.
What is the scribe’s responsibility during the physical exam?
Scribe will listen carefully and watch provider closely in order to provide real-time documentation of the physical exam.
What belongs in the physical exam?
The only thing that belongs in the physical exam section of the chart is what the clinician observes or appreciated. What was seen, heard, felt, smelled during the exam.
What does NOT belong in the Physical Exam section?
- Subjective Symptoms
- Medical History
- Diagnoses
- Any PE findings that were not investigated
Anatomical Terms
- Right and left is ALWAYS for the patient
Anterior
Front of the Body
Posterior
Back of the body
Proximal
Near point of attachment
Distal
Far point of attachment
Medial
Near midline
Lateral
Far from midline
Superior
Above
Inferior
Below
Focal
One area
Diffuse
Widespread
Palmar
Palm of hand
Plantar
Sole of foot
Superficial
On the surface
Deep
Within the tissue/body
Vital Signs
Part of the PE (BP, Pulse, Respiratory Rate, Temp, O2)
Constitutional Body System
The general appearance of the patient. Do they look like they’re in any discomfort, are they alert, are they malnourished? Most likely will be ‘No Acute Discomfort (NAD)’.
Eyes Body System
- PERRL (Are pupils equal, round, reactive to light)
- Extraocular Movements Intact (EOMI) Can eye follow finger
- No Nystagmus (twitching/bouncing action of the eye)
- Sclerae Anicteric (how white is the eye? - if white part of eye is yellow it is indicative of liver failure)
- Normal Conjunctiva (color of the inside of the eye fleshy areas. Is it pale or really red?)
Ears Body System
- Normal Tympanic Membrane (eardrum)
- No canal swelling or tenderness
Nose Body System
- Nasal Discharge
- Normal Nasal Mucosa (swelling > Boggy Turbinates)
- No active bleeding
Throat and Mouth Body System
- Moist Mucus Membranes
- Oropharynx Normal (Throat - is it red, swollen, exudates (white patches indicative of strep), enlarged/asymmetrical tonsils)
- Normal Dentition (teeth - edentulous > lack of teeth ; dental caries > cavities)
Neck Body System
- Supple (they can move next around without stiffness, discomfort, or limited ROM)
- No meningismus
- No tenderness (vertebral point > fracture ; paraspinal tenderness > muscle strain)
- No cervical lymphadenopathy
- No jugular vein distension (JVD) (if it is distended could indicate CHF)
- No thyromegaly (enlarged thyroid)
- No carotid bruit (harsh blood flow noise that is heard through stethoscope indicative of CAD)
Cardiovascular Body System
- Regular Rate (60-100bpm ; tachy - too fast ; brady - to slow)
- Regular Rhythm (regular: b-b-b-b ; regularly irregular: bb-bb-bb-bb- ; irregularly irregular: bb-bbb-b-bb—b-bb-b— (atrial fibrillation))
- Heart Sounds Normal (murmur (whooshing noise) ; rubs (pericarditis) ; gallops (ventricular failure) ; extrasystoles)
Respiratory Body System
- No respiratory distress (breathing is normal ; tachypnea ; accessory muscles use ; pursed lip breathing)
- Clear to auscultation bilaterally (diminished breath sounds, wheezes, rales (crackles), rhonchi)
Gastrointestinal Body System
- Soft (no bloating)
- Nontender (no guarding, rebound tenderness, rigidity)
- Negative Murphy’s Sign (Right upper quadrant above gallbladder)
- Negative McBurney’s point tenderness (Right lower quadrant above appendix)
- Normal Bowel Sounds
- No organomegaly (organ enlargement)
- No masses
Musculoskeletal Body System
- No tenderness (calf tenderness > DVT)
- No Edema (swelling)
- Normal ROM
- Distal CSMT (Circulation, Sensory, Motor, Tendon intact)
Integumentary Body System
- Warm
- Dry
- Normal Color (yellow skin > Jaundice ; blue skin > Cyanotic ; pale skin > Pallor)
- No Rashes (hives > Urticaria ; red dots across skin > Petechiae
- No induration (surrounding area of redness)
- No fluctuance (abscess)
Neurological Body System
- Alert (somnolent, confused, responsive to voice, responsive to painful stimuli, unresponsive to voice/pain)
- Oriented x 4 (disoriented by person, place, time, or situation)
- Speech (patient is not expressive/receptive > aphasia ; not able to articulate speech > dysarthria)
- Strength (grip/lower extremity strength)
- Sensation (decreases/absent sensation)
- Reflexes
