Physical Exam and Diagnosis Flashcards
Disease
Condition in which a common etiology and pathophysiology is confirmed
Syndrome
Cluster of attributes known by a combination of features not clearly related to a single cause
SOAP
Subjective data
Objective data
Assessment
Plan
Inspection
Close careful scrutiny of the body as a whole and each body system
Palpation
Applying touch to assess texture, temperature, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, lumps or masses, tenderness or pain
Percussion
Tapping a patient’s skin with short sharp strokes to assess underlying structures
Auscultation
Listening to sound produced by the body with a stethoscope
FUO
Fever of unknown origin
Normal temperature ranges
Oral - 98.6 +/-1 (F) or 37 +/- 0.6 (C)
Normal pulse ranges
55-100 bpm
Orthostatic hypertension
Increase in blood pressure of greater than 15bpm upon sitting up or standing from supine
Normal respiration ranges
Adult - 14 to 18 cycles per minute
Infant - 44 cycles per minute
Normal blood pressure ranges
<80
Hypertension
> 140/99
PQRST
*Evaluation of pain* Provocation and Palliative Quality Region and Referral Severity (0-10) Time
ABCT
Evaluation of mental status
Appearance - posture, body movement, dress, grooming, hygiene
Behavior - consciousness, facial expression, speech, mood/affect
Cognition - orientation, attention span, recent and remote memory, judgment
Thought processes - thought content, perceptions, anxiety, depression, suicidal thoughts
Levels of consciousness
Alert Lethargic/somnolent Obtunded Stupor or semi-coma Coma
ABCDE
*Examination of skin lesions* Asymmetry Border irregularity Color variation Diameter (greater than 6mm) Elevation or enlargement
Crust
Thickened dried exudate
Scale
Dessicated flakes of keratin
Fissure
Linear crack
Erosion
Shallow scooped-out depression
Ulcer
Deep depression
Excoriation
Self-inflicted abrasion
Scar (atrophic/hypertrophic)
Fibrotic change from wound healing