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auscultation - ANSWER Listening, usually with a stethoscope
palpation - ANSWER The act of pressing on an area of the body
cachectic - ANSWER Emaciated, malnourished
anterior - ANSWER toward the front of the body
posterior - ANSWER toward the back of the body
medial - ANSWER closer to the midline of the body
lateral - ANSWER further from the midline of the body
diffuse - ANSWER widespread (opposite of localized)
distal - ANSWER away from the torso
proximal - ANSWER closer to the torso
objective - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER Detailed Eye
Exam
Hearing/Vision
Assessment GYN Exam
Neurological
Exam
Gait
Assessment
PE- documentation - ANSWER The physical exam is
typically documented
into a template in the
EMR that lists specific
body systems.
Many EMRs default to a normal exam that you must edit.
Bengin exam- external - ANSWER General Well developed, well nourished. No acute
distress
Eyes Anicteric sclerae
ENT No epistaxis
, Neck Supple
Cardiovascular Well perfused
Respiratory No respiratory distress.
Extremities No edema
Skin Warm, Dry, No Rash
Neurological Alert and Oriented. Normal speech
Psychiatric normal effect
benign exam- complete - ANSWER Constitutional Well developed, well nourished. No
acute distress
Eyes PERRL, EOMI
ENT Moist mucous membranes
Neck Supple, no lymphadenopathy
Cardiovascular Regular rate and rhythm. No murmurs, rubs, or gallops.
Distal pulses intact
Respiratory No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales,
or rhonchi.
Abdominal Soft. Non-tender. No guarding, rebound, or rigidity
Extremities No edema, Full ROM
Skin Warm, Dry
Neurological Alert and Oriented. Normal speech
psychiatric normal affect
ANATOMICAL POSITION - ANSWER The anatomical position is a frame of reference
that is used to describe anatomy and movement.
Anatomical Position: Standing erect, facing directly forward, feet pointed forward and
slightly apart, and arms hanging down at the sides with palms facing forward.
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auscultation - ANSWER Listening, usually with a stethoscope
palpation - ANSWER The act of pressing on an area of the body
cachectic - ANSWER Emaciated, malnourished
anterior - ANSWER toward the front of the body
posterior - ANSWER toward the back of the body
medial - ANSWER closer to the midline of the body
lateral - ANSWER further from the midline of the body
diffuse - ANSWER widespread (opposite of localized)
distal - ANSWER away from the torso
proximal - ANSWER closer to the torso
objective - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER Detailed Eye
Exam
Hearing/Vision
Assessment GYN Exam
Neurological
Exam
Gait
Assessment
PE- documentation - ANSWER The physical exam is
typically documented
into a template in the
EMR that lists specific
body systems.
Many EMRs default to a normal exam that you must edit.
Bengin exam- external - ANSWER General Well developed, well nourished. No acute
distress
Eyes Anicteric sclerae
ENT No epistaxis
, Neck Supple
Cardiovascular Well perfused
Respiratory No respiratory distress.
Extremities No edema
Skin Warm, Dry, No Rash
Neurological Alert and Oriented. Normal speech
Psychiatric normal effect
benign exam- complete - ANSWER Constitutional Well developed, well nourished. No
acute distress
Eyes PERRL, EOMI
ENT Moist mucous membranes
Neck Supple, no lymphadenopathy
Cardiovascular Regular rate and rhythm. No murmurs, rubs, or gallops.
Distal pulses intact
Respiratory No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales,
or rhonchi.
Abdominal Soft. Non-tender. No guarding, rebound, or rigidity
Extremities No edema, Full ROM
Skin Warm, Dry
Neurological Alert and Oriented. Normal speech
psychiatric normal affect
ANATOMICAL POSITION - ANSWER The anatomical position is a frame of reference
that is used to describe anatomy and movement.
Anatomical Position: Standing erect, facing directly forward, feet pointed forward and
slightly apart, and arms hanging down at the sides with palms facing forward.
