Physical Assessment & Abbreviations in Progress Notes

Auscultation

________: Involves listening for normal and abnormal sounds with a stethoscope.

PERRLA

________= pupils equal, round, and reactive to light and accommodation.

Percussion

________: Used to produce sounds, elicit tenderness, or assess reflexes in a patient.

Angioplasty

________ or percutaneous coronary intervention (PCI): when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed.

Antimicrobial Stewardship

________= improve how antibiotics are prescribed by clinicians and used by patient.

Palpation

________: the use of the sense of touch in the evaluation of the patient.

FEV1

________- forced expiratory volume in 1 sec.

Pleural effusion

________: fluid in the space between the chest wall and lungs.

Chest radiograph

________ (CXR)- very common when evaluating lung conditions.

Atelectasis

________: partially or fully collapsed lung.

Consolidation

________: areas of the lung where air should be, but it is not.

Infiltrate

________: dead cell, debris, pus commonly seen with pneumonia.

Aspiration

________: inhalation of food particles or stomach contents.

Throat neck

________: inspection of mouth & pharynx, palpation of lymph nodes & glands.

LUQ

________: stomach, spleen, colon, l kidney, pancreas.

Inspection

general observation of the patient

Palpation

the use of the sense of touch in the evaluation of the patient

Percussion

Used to produce sounds, elicit tenderness, or assess reflexes in a patient

Auscultation

Involves listening for normal and abnormal sounds with a stethoscope

Head

Hair, scalp, skull, face, skin

Eyes

general inspection, reactivity of pupils, ophthalmoscopy, extraocular muscles

Ears

internal inspection, otoscope

Throat/neck

inspection of mouth & pharynx, palpation of lymph nodes & glands

Physical exam

inspection, palpation, & auscultation

Chest radiograph (CXR)

very common when evaluating lung conditions

Consolidation

areas of the lung where air should be, but it is not

Infiltrate

dead cell, debris, pus commonly seen with pneumonia

Atelectasis

partially or fully collapsed lung

Pleural effusion

fluid in the space between the chest wall and lungs

Aspiration

inhalation of food particles or stomach contents

coronary angiography

contrast dye is injected through a catheter

Angioplasty or percutaneous coronary intervention (PCI)

when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed

FEV1

forced expiratory volume in 1 sec

FVC

forced vital capacity

Physical exam

assess the 4 quadrants of the abdomen

inspection

color, texture, vascularity, contour

Auscultation

bowel sounds, vascular sounds

Percussion

fluid, gaseous distention, and masses

Palpation

areas of tenderness, muscle spams, or the presence of fluid or masses

RUQ

liver, gall bladder, colon, R kidney, pancreas

RLQ

Appendix, colon, bladder, females ovaries

LUQ

stomach, spleen, colon, l kidney, pancreas

LLQ

colon, female ovaries

Physical exam

Observations & results that start at the top and move down the body

HEENT

head, ears, eyes, nose, throat

If not performed

may document as deferred or not performed

Inspections

general observation of the patient

Palpation

the use of the sense of touch in the evaluation of the patient

Percussion

used to produce sounds, elicit tenderness, or assess reflexes in a patient

Auscultation

Involves listening for normal and abnormal sounds with a stethoscope

Imaging tests

x-ray, MRI

Electrophysiology

EKG, EEG

Screening results

Blood cultures

Risk Calculations

10 yr ASCVD risk

Head exam includes

hair, scalp, skull, face, skin

Eyes exam includes

general inspection, reactivity of pupils, ophthalmoscopy, extraocular muscles

Ear exam includes

internal inspection, otoscopy

Nose exam includes

external inspection/palpation, otoscope

Throat/neck exam includes

inspection of mouth & pharynx, palpation of lymph nodes & glands

NCAT

Normocephalic atraumatic

PERRLA

pupils equal, round, and reactive to light and accommodation

EOMI

extraocular muscles intact

EEG

Measures electrical activity of the brain

RRR

regular rate & rhythm

Chest radiograph (CXR)

very common when evaluating lung cnoditions

Consolidation

areas of the ling where air should be, but it is not

Infiltrate

dead cell, debris, plus commonly seen with pneumonia

Atelectasis

partially or fully collapsed lung

Pleural effusion

fluid in the space between the chest wall and lungs

Aspiration

Inhalation of food particles or stomach contents

Computed tomography (CT) scan

provides better detail than a standard x-ray and may require IV contrast

Echocardiogram

ultrasound of the heart. Provides information about the size, shape, and pumping ability of the heart, as well as visualization of the heart valves

EKG or ECG

measures the electrical activity of the heart. Can show rate & rhythm.

Cardiac catheterization

Going to the cath lab. Procedure to look for disease in the heart muscle, valves or coronary arteries

Coronary angiography

contrast dye is injected through a catheter. X-ray images show the dye as it flows through the heart arteries. This shows if the arteries are open or blocked

Angioplasty or percutaneous coronary intervention (PCI)

when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed

Pulmonary function test (PFT)

measure of ling volumes. Uses FEV1 and FVC

FEV1

forced expiratory volume in 1 sec

FVC

forced vital capacity

(EGD) Esophagogastroduodenoscopy

endoscopic procedure that examines the esophagus, stomach and duodenum. It may help locate a GI bleed

Doppler Ultrasound

quick way to check for problems with blood flow

DVT

deep vein thrombosis

Urine

Urinary tract infection

Lungs

Pneumonia

Skin

cellulitis

empiric coverage

we often start antibiotics to help with the infection before we know what bacteria is growing

Antimicrobial Stewardship

improve how antibiotics are prescribed by clinicians and used by patient

(S) sensitive

bacteria will be killed by antibiotics

(R) resistant

bacteria will not be killed by antibiotic