ScribeAmerica Outpatient Course 4, ScribeAmerica OP Course 3, ScribeAmerica OP Course 2, ScribeAmerica OP Course 1 | combined | updated 2023/24

ScribeAmerica Outpatient Course 4, ScribeAmerica OP Course 3, ScribeAmerica OP Course 2, ScribeAmerica OP Course 1 | combined | updated 2023/24 auscultation - Listening, usually with a stethoscope palpation - The act of pressing on an area of the body cachectic - Emaciated, malnourished anterior - toward the front of the body posterior - toward the back of the body medial - closer to the midline of the body lateral - further from the midline of the body diffuse - widespread (opposite of localized) distal - away from the torso proximal - closer to the torso objective - Objective information comes directly from a • Healthcare provider's observation (what the provider saw, heard, felt, or smelled) - OR - • Diagnostic test (vital signs, labs, or imaging) includes vital signs, PE, orders/results vital signs - BP, heart rate, respiratory rate, temperature, oxygen saturation Vital signs are typically obtained by the nurse or MA upon patient check-in. • It is your responsibility to make sure they're documented in the chart Vital signs may change throughout a visit, and the physician may want to have more than one set of vital signs recorded, particularly if one is abnormal. Example: On arrival, patient's blood pressure is 170/100. Pt is given an antihypertensive while waiting for his appointment. Repeat blood pressure was 140/90 prior to check-out vital signs - Many times, vital signs are the objective evaluation for patient's subjective complaints: It is important to get a temperature for a patient complaining of fever A patient with an appointment for HTN management should have a BP taken on arrival If the patient has severe COPD, O2 saturation is a requirement Vital signs often help a physician determine how severe a problem is and the treatment plan will be adjusted accordingly. physical exam - The physician is performing his physical exam from the moment he walks into the room. In fact, much of a physical exam can be completed within the first 30 seconds of talking to the patient. 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 Physical exam- basic - Looking at the patient General appearance, eyes, skin Auscultating the heart Heart rate and rhythm, murmur Auscultating the lungs Breath sounds Palpating the abdomen Abdominal tenderness, soft Examining the legs Edema, distal pulses, tenderness physical exam- detailed - Detailed Eye Exam Hearing/Vision Assessment GYN Exam Neurological Exam Gait Assessment PE- documentation - The physical exam is typically documented into a template in the