History and Physical Exam

lymph adenopathy (LAD)

swollen lymph nodes

Jugular venous distension (JVD)

Bulging of major veins in neck

ENT

ears, nose, throat

Z pack

brand azithromycin

what are Z packs used for?

bacterial infections

Chief Complaint (CC)

patient’s own words

HPI

history of present illness

PMHx

past medical history

SHx

surgical/social history

FHx

family history

A&O x 3

alert and oriented to person, place, and time (or axious)

when evaluating head and neck, what do you tell the pt to do?

touch chin to chest

when evaluating neuro what 4 things are you looking at?

A&O x 3, pupils, reflexes, MMSE

MMSE

Mini Mental State Examination

when evaluating neuro what 5 things are you looking at?

supple, LAD, JVD, sinuses, ENT

how do you evaluate sinuses in a head and neck examination?

tapping

when evaluating cardiac what 3 things are you listening for?

rhythm, murmurs, deviation

when evaluating resp what 2 things are you listening for?

quality and quantity of breath sounds

when evaluating abdomen what 5 things are you looking at?

scars, distension, focal/diffuse/rebound tenderness, masses, rectal exam

focal tenderness

pain localized to one spot

diffuse tenderness

widespread, generalized tenderness

rebound tenderness

tenderness that hurts upon release of pressure

what are you looking at in a rectal exam?

blood in stool

when evaluating extremities what 5 things are you looking at?

trauma, edema, venous congestion, pulses, rashes venou

venous congestion

blood pools in a vein

why does venous congestion happen?

blood not flowing back to the heart properly