What types of things are included in objective observations?
Symptoms that can be measured, seen, heard, touched, felt, or smelled. Also, vital signs
... [Show More] such as temperature, pulse, and respiration, physical exam findings, and the results of diagnostic tests
True or False; The physician is performing their physical exam from the moment they walk into the room
True
What kinds of things can physicians visually evaluate the moment they walk into the room to do a physical exam?
General - Do they look like they are in pain?
Eyes - Are the sclera yellow?
Pulmonary - Are they breathing comfortably?
Skin - Is their skin a normal color?
Neurological - Are they answering questions appropriately?
Psychiatric - Are they acting normally?
How many elements are required for a complete Physical Exam?
8 Elements
What is an example of a Benign External Exam?
General - Well developed, Well nourished, No acute distress
Eyes - PERRL
ENT - Moist mucosa
Neck - Supple
Cardiovascular - Well perfused
Respiratory - No respiratory distress
Gastrointestinal - Non-distended
Extremities - No edema
Skin - Dry, no rashes
Neurological - A&O, Normal Speech
Psychiatric - Normal affect
What is an External exam?
A physical exam that requires no touch
What is an example of a Complete Benign Exam?
Constitutional - Well developed, well nourished, NAD
Eyes - PERRL, EOMI
ENT - Moist mucous membranes
Neck - Supple, No lymphadenopathy
Cardiovascular - Well perfused, RRR, No mumurs, rubs, or gallops. Distal pulses intact
Respiratory - No respiratory distress, Clear to auscultation bilaterally. No wheezes, rales, or rhonchi
Abdominal - Non-distended. Soft. Non-tender, No guarding, rebound, or rigidity
Extremities - No edema, Full ROM
Skin - Dry, No rashes. Warm
Neurological - A&O. Normal speech
Psychiatric - normal affect
What types of exam findings are categorized under External Inspection?
No acute distress. Well developed. Well developed, well nourished. PERRL. Moist mucosa. Supple neck. No respiratory distress. Skin is warm and dry. A&O. Normal affect.
What types of exam findings are categorized under Auscultating the Heart?
Regular rate and rhythm. No murmurs, rubs, or gallops
What types of exam findings are categorized under Auscultating the Lungs?
Clear to auscultation bilaterally. No wheezes, rales, or rhonchi
What types of exam findings are categorized under Palpating the Abdomen?
Soft. Non-tender. Non-distended. No guarding, rebound, or rigidity
What types of exam findings are categorized under Examining the legs?
No edema. Distal pulses intact
What are some common extra exam findings?
Pharyngeal erythema or exudates, TM erythema or bulging, Hyperactive/Hypoactive bowel sounds, Radial pulses, Calf tenderness, CVA tenderness
If a physician is examining the throat during a PE, what are they looking for?
Pharyngeal erythema or exudates
If a physician is examining the inner-ear during a PE, what are they looking for?
TM (ear-drum) erythema or bulging
If a physician is auscultating the abdomen during a PE, what are they looking for?
Hyper/Hypoactive bowel sounds
What is a physician looking for if they touch a patient's wrist during a PE?
Radial pulses
If a physician pounds a patient's back during a PE, what are they checking for?
CVA tenderness
If a physician squeezes a patient's calf muscle during a PE, what are they checking for?
Calf tenderness
What is anatomical position?
Standing erect, facing directly forward, feet pointed forward and slightly apart, and arms hanging down at the sides with palms facing forward
Are PE findings always documented in terms of at the patient's anatomical position?
Yes
What are the abdominal quadrants?
Epigastrium, RUQ, LUQ, RLQ, LLQ, Suprapubic, Periumbilical (R Flank/L Flank) [Show Less]