The Physical Exam Flashcards
Objective data
- observation
- exam
- observable and can be measured
- obtained from diagnostic lab and radiological testing
Exam setting
- privacy
- comfort
- quiet
- lighting
- exam table
- equipment
Preparation for physical exam
establish relationship (build rapport), explain procedure, respect requests (even if necessary, just document if they refuse), wash hands, protect self, special circumstances (might need witness), leave room while changing, provide necessary container for sample, start w/ less intrusive procedures/explain what doing, explain position changes (why necessary)
Approaches
- relationship
- educate
- respect
* first - *bladder, least intrusive to most, teach
Positions to know
- sitting
- supine
- dorsal recumbent
- sims’
- standing
- prone
- knee-chest
- lithotomy
Supine
lying on the back
dorsal recumbent
lying on back with legs bent and feet flat
sims position
lying on left side with right knee drawn up and with left arm drawn behind parallel to the back
prone
lying face down
knee-chest position
patient is lying face down with the hips bent so that the knees and chest rest on the table
Lithotomy position
lying on back with legs raised and feet in stirrups
OBGYN position
order of physical exam
- inspect
- palpate
- percuss
- auscultate
Inspect
- begins at the beginning, ends at the end
- lights
- expose with privacy in mind
- use your senses
What are you looking for during inspection?
color, pattern, size, location, consistency, symmetry, movement, behavior, odor and sounds
Palpate
Use your hand to touch and feel for the following:
* texture (rough or smooth)
* temperature (warm)
* Moisture (dry or wet)
* Mobility (fixed, movable, still, vibrating)
* consistency (soft)
* strength of pulses (strong, weak, thread, bounding)
* size
* Shape (well defin, irregular)
* degree of tenderness
