IPDM I Lect 2 PE definitions

alchemist04's version from 2016-04-14 14:10


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PEPhysical Exam perform by a medical professional to investigate a patient's body for sign of disease
Medical Historysymptoms experienced by the patient
Differential diagnosislist of potential cause of symptoms
Medical Recordsit is where the diagnosis and treatment plan are recorded


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SOAPSubjective, Objective, Assessment, Plans
SubjectiveWhat the patient tells you, History from the patient or 3rd party, I fell down
ObjectiveInformation from the provider, medical history, vitals, lab report etc
Assessmentprovider observation and conclusion based on the findings from subjective, objective, signs and symptoms
Planwhat you'll do, involves treatment, monitoring and follow up


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VitalsTemp, BP, HR/Pulse, Resp. Pain
Normal HR60-90 beats per minutes
Normal RR12-20


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A patient with RR of 28 has ....?Tachypnea
A patient with 40 HR has ....?Bradyarrhythmia or Bradycardia
A patient with 100 HR per minutes has ...?Tachyarrhythmia or Tachcardia
A patient with RR of 10 has ....?Bradypnea


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SBP/DBPSystolic up /Diastolic down
Normal range of temperature98.6 -100.3 F
Normal range of BP<120/<80
Pre-hypertension (HTN)(120 -139) / (80 -89)
Stage 1 HTN(140-159) / (90-99)
Stage 2 HTN(>160) / (>100)
What stage is BP of 143/81 mmHg?Stage 1 HTN


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Pain @ 0 levelNo pain
Pain @ 2 levelmild pain
Pain @ 4 levelModerate pain
Pain @ 6 levelSevere pain
Pain @ 10 levelWorst pain


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HEENTHead, Eyes, Ears, Nose, Throat
WDWNWell-developed, Well-nourished
NTNDNon-tendered Non-distended
NADNo acute Distress


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Light reactionShinning light in one eye shd constrict that eye's pupil (direct reaction) and in the opposite eye (consensual reaction)
Accommodationability of eye to change its focus from distance to near objects (and vice versa)
Level of consciousnessAlert, Lethargic, Stuporous, Comatose


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PERLAPupils Equal & Reactive to light & Accommodation
EOMIExtra Ocular Movements Intact
JVDJugular Venous Distension
RRRRegular Rate and Rhythm
No m/g/rNo murmur, gallop, rubs
CTA BLClear to auscultation bilaterally
+ BSBowel sounds present


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Normal JVD< 4 cm
+ JVD or sign of positive JVD=/> 4cm (sign of heart failure)


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SIFirst heart sound (lub)
S2second heart sound (dub)
S3/S4gallop, abnormal, black flow, lub dub
MurmurTurbulent blood flow (benign or pathological)
RubPericardial friction


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Mitral and tricuspid valve closureS1
Pulmonic and aortic valve closureS2
Heard at the ApexS1
Heard at the baseS2
+ S1Normal lub
+ S2Normal dub


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5 areas of listening to the heartAll People Enjoy Time Magazine
Aorticright 2nd intercostal space
Pulmonicleft 2nd intercostal space
ERB's Point(S1 S2) Left 3rd intercostal space
TricuspidLower left Sternal Border, 4th Intercostal
MitralLeft 5th intercostal, Medial to Midclavicular Line


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What are the 4 Physical Examinations Overlaping with the CV examJVD, Clubbing, Cyanosis, Peripheral edema.
Which of these is part of Physical Examinations Overlapping with the CV exams (a) RRR (b) JVD (c) Clubbing (d) Cyanosis (e) PERLA (f) NAD (g) Peripheral edemaJVD, Clubbing, Cyanosis, Peripheral Edema.


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NTNDNon-tendered Non-distended
ROMRange of motion
LROMLimited Range of Motion
4 quadrantsLUQ, RUQ, LLQ, RLQ
A&O x4Alert and Oriented to person, place, time, and situation


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BruitMurmur sound as a result of obstruction
Epigastric bruit meansmurmur-like sound that is caused by turbulent blood flow, usually indicating an obstruction
Epigastric bruitsuggestive of renal artery stenosis
What are the 2 types of PercussionDullness, Resonant
DullnessNot so loud noise experience at the top of the abdomen during percussion
ResonantThe loud noise during percussion of the chest.
What are the 2 types of PalpationLight Palpation, Deep Palpation


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What are the steps to respiratory exam(1) Inspection (2) Palpation (3) Percussion (4) Auscultation
What are the steps to Abdominal Examination?(1) Inspection (2) Palpation (3) Percurssion (4) Auscultation
Where do you listen to Bruits?on aorta and Epigastric area
What does Epigastric bruit suggest?Renal Artery Stenosis


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What are the five area for listening to the heart? Hint= All People Enjoy Time Magazine(1) Aortic (2) Pulmonic (3) ERB (4) Triscupid (5) Mitral
What are the examples of CV Exam on a Soap Note?(1) RRR (2) No m/g/r (3) +S1 (4) +S2
What are the examples of HEENT Exam on a Soap Note?(1) NC (2) PERLA (3) EOMI (4)Erythemal BL
What are the examples of Neck Exam on a Soap Note?(1) Noraml JVD (2) + JVD
What are the examples of Respiratory Exam on a Soap Note?CTA BL
What are the examples of Abdominal Exam on a Soap Note?(1) NTND (2) +BS (3) - epigastric bruit (4) No Scars (5) Hepatomegaly (6) No palpable
What are the examples of Musculoskeletal Exam on a Soap Note?(1) LROM (2) ROM
What are the examples of Neurological Exam on a Soap Note?A&O x4

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