Physical Exam Flashcards
Objective info
is factual info
- what the health provider observed using his senses / physical exam results from provider
- diagnostic results like vital signs, labs, imaging
NAD = no acute distress
- patient is in no acute distress
- patient does not appear to have discomfort/feel pain
No scleral icterus or jaunice
-no yellowing to white of eyes (scleral icterus) or skin (jaundice)
No respiratory distress
-they seem to be breathing comfortably
Grossly neurologically intact
-able to answer questions appropriately w/o obvious focal neurological defects
Auscultation
-listening, usually w/ stethoscope
Palpation
pressing on area of body
Exam types
1) external inspection- any obvious abnormalities, discomfort
- NAD, nourished, PERRL, skin is dry, alert and oriented
2) auscultating heart
- regular rate and rhythm. no murmurs, rubs, gallops
3) auscultate lungs
- clear to auscultation bilaterally (both lungs)
- no wheezes, rales, rhonchi
4) palpating abdomen
- soft, non-tender, non-distended
- no guarding, rebound, rigidity
5) examining legs
- extremity swelling, pain, abnormal pulses
- no edema, distal pulses intact
PERRL
pupils equal, round, reactive to light
murmur
-whoosh/swoosh sound of turbulent blood in heart
heart rub
pericardial rub
- sound of scraping, grating
- inflamed pericardium
heart gallop
- extra heart sound after lub-dub
- rapid ventricular filling
- ventricular bulge, low freq sound
- may be a sign of heart disease, like harmed left ventricle
wheeze
-whistle/rattle sound while breathing
rales
-small click/bubbling sound when inhaling
rhonchi
-snore-like sound
abdominal guarding
-tensing of abdominal wall muscles to guard inflamed organs w/in abdomen from pressure/pain
abdominal rebound
Blumberg’s sign
- pain upon removal of pressure rather than when pressure is applied (which would be abdominal tenderness)
- indicates peritonitis
abdominal rigidity
-stiffness of muscles in belly, which can be felt when touched/pressed
Examining throat = looking for…
- pharyngeal erythema (Redness of mucous membranes)
- exudates- leaking fluid from blood vessels
Examining inner ear = looking for…
- TM (tympanic membrane/ear drum) erythema
- TM bulging
Auscultates abdomen = looking for…
Hyperactive/hypoactive bowel sounds
Touches wrists = looking for…
radial pulses
Squeezes calf muscles = looking for…
calf tenderness
“Pounds” on back = looking for…
CVA tenderness
-cerebrovascular accident = stroke but this CVA is talking about costovertebral angle tenderness
Anatomical position
- Standing erect, facing directly forward
- feet pointed forward and slightly apart
- arms hanging down at the sides
- palms facing forward
anterior/ventral, posterior/dorsal, lateral, medial, proximal, distal
Document correct laterality- Patient’s right and left
