OP 4: Objective

Question 1

Objective Information

Answer 1

Factual information that comes directly from a healthcare providers observations and diagnostic tests.

Question 2

What are the three components to the objective evaluation?

Answer 2

1. Vital Signs
2. Physical Exam
3. Orders/Results

Question 3

Physical Exam

Answer 3

When the clinician evaluates each body system (eyes, heart, lungs, skin, etc.) by inspection, palpation, and auscultation. It is important because the physical exam investigates patient complaints and helps the provider to narrow down or even rule out certain diseases/problems.

Question 4

What is the scribe’s responsibility during the physical exam?

Answer 4

Scribe will listen carefully and watch provider closely in order to provide real-time documentation of the physical exam.

Question 5

What belongs in the physical exam?

Answer 5

The only thing that belongs in the physical exam section of the chart is what the clinician observes or appreciated. What was seen, heard, felt, smelled during the exam.

Question 6

What does NOT belong in the Physical Exam section?

Answer 6

• Subjective Symptoms
• Medical History
• Diagnoses
• Any PE findings that were not investigated

Question 7

Anatomical Terms

Answer 7

• Right and left is ALWAYS for the patient

Question 8

Anterior

Answer 8

Front of the Body

Question 9

Posterior

Answer 9

Back of the body

Question 10

Proximal

Answer 10

Near point of attachment

Question 11

Distal

Answer 11

Far point of attachment

Question 12

Medial

Answer 12

Near midline

Question 13

Lateral

Answer 13

Far from midline

Question 14

Superior

Answer 14

Above

Question 15

Inferior

Answer 15

Below

Question 16

Focal

Answer 16

One area

Question 17

Diffuse

Answer 17

Widespread

Question 18

Palmar

Answer 18

Palm of hand

Question 19

Plantar

Answer 19

Sole of foot

Question 20

Superficial

Answer 20

On the surface

Question 21

Deep

Answer 21

Within the tissue/body

Question 22

Vital Signs

Answer 22

Part of the PE (BP, Pulse, Respiratory Rate, Temp, O2)

Question 23

Constitutional Body System

Answer 23

The general appearance of the patient. Do they look like they’re in any discomfort, are they alert, are they malnourished? Most likely will be ‘No Acute Discomfort (NAD)’.

Question 24

Eyes Body System

Answer 24

• PERRL (Are pupils equal, round, reactive to light)
• Extraocular Movements Intact (EOMI) Can eye follow finger
• No Nystagmus (twitching/bouncing action of the eye)
• Sclerae Anicteric (how white is the eye? - if white part of eye is yellow it is indicative of liver failure)
• Normal Conjunctiva (color of the inside of the eye fleshy areas. Is it pale or really red?)

Question 25

Ears Body System

Answer 25

• Normal Tympanic Membrane (eardrum)
• No canal swelling or tenderness

Question 26

Nose Body System

Answer 26

• Nasal Discharge
• Normal Nasal Mucosa (swelling > Boggy Turbinates)
• No active bleeding

Question 27

Throat and Mouth Body System

Answer 27

• Moist Mucus Membranes
• Oropharynx Normal (Throat - is it red, swollen, exudates (white patches indicative of strep), enlarged/asymmetrical tonsils)
• Normal Dentition (teeth - edentulous > lack of teeth ; dental caries > cavities)

Question 28

Neck Body System

Answer 28

• Supple (they can move next around without stiffness, discomfort, or limited ROM)
• No meningismus
• No tenderness (vertebral point > fracture ; paraspinal tenderness > muscle strain)
• No cervical lymphadenopathy
• No jugular vein distension (JVD) (if it is distended could indicate CHF)
• No thyromegaly (enlarged thyroid)
• No carotid bruit (harsh blood flow noise that is heard through stethoscope indicative of CAD)

Question 29

Cardiovascular Body System

Answer 29

• Regular Rate (60-100bpm ; tachy - too fast ; brady - to slow)
• Regular Rhythm (regular: b-b-b-b ; regularly irregular: bb-bb-bb-bb- ; irregularly irregular: bb-bbb-b-bb—b-bb-b— (atrial fibrillation))
• Heart Sounds Normal (murmur (whooshing noise) ; rubs (pericarditis) ; gallops (ventricular failure) ; extrasystoles)

Question 30

Respiratory Body System

Answer 30

• No respiratory distress (breathing is normal ; tachypnea ; accessory muscles use ; pursed lip breathing)
• Clear to auscultation bilaterally (diminished breath sounds, wheezes, rales (crackles), rhonchi)

Question 31

Gastrointestinal Body System

Answer 31

• Soft (no bloating)
• Nontender (no guarding, rebound tenderness, rigidity)
• Negative Murphy’s Sign (Right upper quadrant above gallbladder)
• Negative McBurney’s point tenderness (Right lower quadrant above appendix)
• Normal Bowel Sounds
• No organomegaly (organ enlargement)
• No masses

Question 32

Musculoskeletal Body System

Answer 32

• No tenderness (calf tenderness > DVT)
• No Edema (swelling)
• Normal ROM
• Distal CSMT (Circulation, Sensory, Motor, Tendon intact)

Question 33

Integumentary Body System

Answer 33

• Warm
• Dry
• Normal Color (yellow skin > Jaundice ; blue skin > Cyanotic ; pale skin > Pallor)
• No Rashes (hives > Urticaria ; red dots across skin > Petechiae
• No induration (surrounding area of redness)
• No fluctuance (abscess)

Question 34

Neurological Body System

Answer 34

• Alert (somnolent, confused, responsive to voice, responsive to painful stimuli, unresponsive to voice/pain)
• Oriented x 4 (disoriented by person, place, time, or situation)
• Speech (patient is not expressive/receptive > aphasia ; not able to articulate speech > dysarthria)
• Strength (grip/lower extremity strength)
• Sensation (decreases/absent sensation)
• Reflexes