OP 4: Objective

Question 1

Objective

Answer 1

Healthcare provider’s observations
Includes:
- Vital signs
- PE
- Orders/Results

Question 2

Physical Exam

Answer 2

When the physician evaluates each body system by inspection, palpation, and auscultation

Question 3

RUE

Answer 3

Right upper extremity

Question 4

LUE

Answer 4

Left upper extremity

Question 5

RLE

Answer 5

Right lower extremity

Question 6

LLE

Answer 6

Left lower extremity

Question 7

Vital Signs

Answer 7

1. Blood Pressure
2. Pulse Rate
3. Respiratory rates
4. Temperature
5. Oxygen Saturation (SpO2)

Question 8

Blood Pressure

Answer 8

Healthy: 120/80
Hypotensive: < 90/60 mm Hg
Hypertensive: > 120/80 mm Hg

Question 9

Pulse Rate

Answer 9

Healthy: 60 - 100 bpm
Bradycardic: < 60 bpm
Tachycardic: > 100 bpm

Question 10

Respiratory Rate

Answer 10

Healthy: 12-20
Bradypneic: <12
Tachypneic: >20

Question 11

Temperature

Answer 11

Healthy: 98.6
Hypothermic: 97.8
Febrile: 100.4

Question 12

Oxygen Saturation (SpO2)

Answer 12

Healthy: >96%
Hypoxic: <93%

Question 13

Consitutional

Answer 13

General appearance of patient

Normal:
- NAD (No Acute Distress)
- Well-developed
- Well-nourished
- Alert

Abnormal:
- Mild/Moderate/Severe Distress
- Cachetic, emaciated, malnourished
- Somnolent, obtunded, unresponsive, drowsy

Question 14

Eyes

Answer 14

Investigation: Visual

Normal:
- Pupils Equal, Round, Reactive to Ligh (PERRL)
- Extraocular Movements Intact (EOMI)
- No nystagmus
- Sclerae anticteric
- Normal conjunctiva

Abnormal:
- Pupils fixed and dilated
- EOM entrapment
- Nystamus
- Scleral icterus
- Pale conjunctiva, conjunctival infection, subconjunctival hemorrhage, discharge or crusting

Question 15

Ears

Answer 15

Investigation: Visual

Normal:
- Tympanic Membrane (TM) normal
- No canal swelling or tenderness

Abnormal: (otitis medina)
- TM erythema
- TM bulging
- TM dullness
- Canal swelling or tenderness (otitis externa)

Question 16

Nose

Answer 16

Investigation: visual

Normal:
- No discharge
- Normal nasal mucosa
- No active bleeding

Abnormal:
- Clear or yellow discharge
- Boggy turbinates/swelling of nasal mucosa (allergic rhinitis)
- Site of bleeding identified (anterior epistaxis)

Question 17

Throat & Mouth

Answer 17

Inves: Visual

Normal:
- Moist mucous membranes
- Oropharynx normal
- Normal dentition

Abnormal:
- Dry mucous membranes
- Pharyngeal erythema
- Exudates
- Tonsillar hypertrophy
- Tonsillar asymmetry
- Uvular shift
- Edentulous
- Dental caries

Question 17

Neck

Answer 17

Inves: patient moves neck, palpates

Normal:
- Supple
- No meningismus
- No tenderness
- No cervical lymphadenopathy
- No jugular vein distention (JVD)
- No thyromegaly
- No carotid bruit

Abnormal:
- Limited ROM
- Positive Brudzinski’s sign
- Vertebral point (fracture)
- Paraspinal tenderness (muscle strain)
- Cervical lymphadenopathy
- Jugular vein distention (JVD)
- Thyromegaly
- Carotid bruit

Question 18

Cardiovascular

Answer 18

Inves: auscultation

Normal:
- Regular rate and rhythm
- Normal heart sounds

Abnormal:
- Tachycardia (>100 bpm)
- Bradycardia (<60 bpm)
- Irregularly Irregular Rhythm
- Murmurs
- Rubs
- Gallops
- Extrasystoles

Question 19

Pulses

Answer 19

Inves:
- Carotid = neck
- Radial = wrist
- Femoral = groin
- Dorsalis Pedis (DP) = Top of foot
- Posterior Tibial (PT) = Back of ankle

Normal:
- 2+ (easily palpable/normal)
- Capillary refill <2 sec

Abnormal:
- 0 (Absent pulse)
- 1+ (Barely palpable)
- 3+ (Full)
- 4 + (Bounding/Aneurysmal)
- Delayed capillary refill (visual/presses on fingers & toes)

Question 20

Respiratory

Answer 20

Normal:
- No respiratory distress
- Clear to auscultation bilaterally

Abnormal:
- Mild/moderate/severe respiratory distress
- Tachypnea
- Accessory muscle use
- Pursed lip breathing
- Diminished breath sounds
- Wheezing
- Rales/crackles
- Rhonchi

Question 21

Gastrointestinal

Answer 21

Inves: Palpation, Auscultation

Normal:
- Soft
- Non-tender
- Negative Murphy’s sign
- Negative McBurney’s point tenderness
- Bowel sounds
- No organomegaly
- No masses

Abnormal:
- Distended
- Mild/moderate/severe tenderness
- Guarding
- Rebound
- Rigidity
- Positive Murphy’s sign (cholecystitis)
- Positive McBurney’s point tenderness (appendicitis)
- Absent/Hypoactive/Hyperactive Bowel Sounds
- Hepatomegaly (liver)
- Splenomegaly (spleen)
- Abnormal massed

Question 22

Musculoskeletal

Answer 22

Inves: Palpation, Visual

Normal:
- No tenderness
- No edema
- Normal ROM
- Distal CSMT (Circulation, Sensory, Motor, Tendon)

Abnormal:
- Bony tenderness (fracture)
- Soft tissue tenderness (confusion, strain)
- Calf tenderness (DVT)
- Edema (trace to 4+)
- Limited ROM
- Pulse/Sensory/Motor deficits
- Tendon laxity

Question 23

Skin/Integumentary

Answer 23

Inves: Visual, palpation

Normal:
- Warm
- Dry
- Normal color
- No rashes
- No induration
- No fluctulance

Abnormal:
- Cool or hot to touch
- Diaphoretic
- Jaundice, Cyanotic, Pallor
- Urticaria/whats, Petechiae
- Induration, Fluctulunce, Purulent drainage

Question 24

Neurological

Answer 24

Normal:
- Alert
- Oriented x4
- Normal speech
- Motor Strength 5/5 and Symmetric
- Sensation intact
- Reflexes 2+ and symmetric

Abnormal:
- Somnolent, confused, responsive to painful stimuli, unresponsive to voice and pain
- Disoriented to person, place, time or situation
- Aphasia, Dysarthria
- Pronator drift, Grip/lower extremity strength: 0-4
- Hypoesthesia, Numbness
- 0-4+ Reflexes

Question 25

Psychological

Answer 25

Normal:
- Normal affect
- No SI or HI
- No auditory/visual hallucinations

Abnormal:
- Odd/flat/depressed affect
- SI or HI w/ or w/out plan
- Auditory/visual hallucinations