• subjective verses objective data and where to document it
Subjective: data that pt says, document in interview/PMH/review of systemsObjective: data from observation, document in exams
• lymph node examination
OccipitalPost AuricularPre AuricularParotidTonsillarSubmandibularSubmentalAnterior CervicalDeep CervicalSupraclavicularMobile, non tender, non palpable
• lung examination, abnormal findings included
Anteroposterior diameter = 2:1symmetric chest expansion Fremitus is a palpable vibrationPercussion: resonance is low-pitched, clear, hollow sound Auscultate with diaphragm Bronchial: Trachea and larynxBronchovesicular: over major bronchiVesicular: over peripheral lung fields
Adventitious Lung Sounds
Discontinuous sounds:Crackles—fineCrackles—courseAtelectatic cracklesPleural friction rubContinuous sounds:Wheeze— sibilant - high pitch/musicalWheeze—sonorous rhonchi - low pitchStridor - inflammation, whistlemoving air colliding with secretions/ popping open of previously deflated airways
Abnormal Findings: Respiration Patterns
SighTachypneaBradypneaHyperventilationHypoventilationCheyne-Stokes respiration (irregular before death)Chronic obstructive breathing (tripod, pursed lips)
• murmur pathophysiology (not specific murmurs)
turbulent blood flow and collision currentsabnormal movement of blood across valves and between chambersgentle, blowing, swooshing sound (low pitch)
• why is it important to attempt to palpate all peripheral pulses
Check that all areas have blood circulating and no clots are present
• how to document pulse quality and landmarks for peripheral pulses
4+ = bounding3+ = increased2+ = normal1+ = weak, diminished0 = absent Radial: thumb side of wristFemoral: below inguinial ligamentPopliteal: back of knee, in popliteal fossaDorsalis pedis: lateral to extensor tendon of big toePosterior Tibia: medial malleous
• what do the cardiac sounds represent and where is the PMI & why would it be misplaced
S1: closure of AV valves (tricuspid and mitral), beginning of systole, loudest at apexS2:closure of semilunar valves (pulmonic and aortic), end of systole, loudest at baseS3: Fluid volume overloadS4: sound is ventricular filling, end of diastolePMI: 5th intercostal space, midclavicular line
• how would you document findings of edema
+0 = no edema+1 = barely+2 = mild, < 0.6 cm, < 15 seconds+3 = moderate, 0.6-1.3 cm, 15 to 30 seconds+4 = severe, 1.3-2.5 cm, > 30 seconds
• examination and patient teaching for skin
A: asymmetryB: borderC: colorD: diameterE: elevation and enlargement
• breast exam findings
Note any localized areas of redness, bulging, or dimplingAxilla: bulging, discoloration, or edemaNipple: dry scaling, any fissure or ulceration, and bleeding or other dischargeboth breasts should move up symmetricallyMale Breast Cancer: 1%
• proper neuro exam techniques and CN exam / cerebellar function tests and findings
Eyes:-Snellen charts-pupil reflex-cardinal gazes-look down & in-lateral movement-open & close eyesNose: -Sniff testEars:-whisper test-tuning forks (Rhine & Weber)Mouth:-swallow-cough-stick out tongue-say ahhh, light tight dynamite-gag reflexFace:-jaw strength-smile, frown-puff cheeks-sharp/dull-cottonMuscles:-shrug (trapezius)-turn head side to side (sternomastoid)Cerebellar:-rapid alternating movement-finger to nose-heel to shin
• throat examination, normal versus abnormal
-Symmetry-Trachea postion-thyroid cartilage
• bell versus diaphram of stethoscope and why
Diaphragm: larger side, high frequencyBell: smaller side, low frequency
• dorsal versus ventral
Dorsal: posterior/backVentral: anterior/front