Physical Exam

Question 1

Objective info

Answer 1

is factual info

• what the health provider observed using his senses / physical exam results from provider
• diagnostic results like vital signs, labs, imaging

Question 2

NAD = no acute distress

Answer 2

• patient is in no acute distress

- patient does not appear to have discomfort/feel pain

Question 3

No scleral icterus or jaunice

Answer 3

-no yellowing to white of eyes (scleral icterus) or skin (jaundice)

Question 4

No respiratory distress

Answer 4

-they seem to be breathing comfortably

Question 5

Grossly neurologically intact

Answer 5

-able to answer questions appropriately w/o obvious focal neurological defects

Question 6

Auscultation

Answer 6

-listening, usually w/ stethoscope

Question 7

Palpation

Answer 7

pressing on area of body

Question 8

Exam types

Answer 8

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

Question 9

PERRL

Answer 9

pupils equal, round, reactive to light

Question 10

murmur

Answer 10

-whoosh/swoosh sound of turbulent blood in heart

Question 11

heart rub

Answer 11

pericardial rub

• sound of scraping, grating
• inflamed pericardium

Question 12

heart gallop

Answer 12

• 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

Question 13

wheeze

Answer 13

-whistle/rattle sound while breathing

Question 14

rales

Answer 14

-small click/bubbling sound when inhaling

Question 15

rhonchi

Answer 15

-snore-like sound

Question 16

abdominal guarding

Answer 16

-tensing of abdominal wall muscles to guard inflamed organs w/in abdomen from pressure/pain

Question 17

abdominal rebound

Answer 17

Blumberg’s sign

• pain upon removal of pressure rather than when pressure is applied (which would be abdominal tenderness)
• indicates peritonitis

Question 18

abdominal rigidity

Answer 18

-stiffness of muscles in belly, which can be felt when touched/pressed

Question 19

Examining throat = looking for…

Answer 19

• pharyngeal erythema (Redness of mucous membranes)

- exudates- leaking fluid from blood vessels

Question 20

Examining inner ear = looking for…

Answer 20

• TM (tympanic membrane/ear drum) erythema

- TM bulging

Question 21

Auscultates abdomen = looking for…

Answer 21

Hyperactive/hypoactive bowel sounds

Question 22

Touches wrists = looking for…

Answer 22

radial pulses

Question 23

Squeezes calf muscles = looking for…

Answer 23

calf tenderness

Question 24

“Pounds” on back = looking for…

Answer 24

CVA tenderness

-cerebrovascular accident = stroke but this CVA is talking about costovertebral angle tenderness

Question 25

Anatomical position

Answer 25

• 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