Physical Assessment & Abbreviations in Progress Notes

Physical Exam

  • 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

Diagnostic Test

  • May be the actual image of an organ or an interpretation of what was seen   * Imaging tests (X-ray, MRI)   * Electrophysiology (EKG, EEG)   * Screening results (blood cultures)   * Risk calculations (10 yr ASCVD)

Physical exam

  • 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

NCAT= Normocephalic atraumatic

PERRLA= pupils equal, round, and reactive to light and accommodation

EOMI= extraocular muscles intact

Imaging= can visualize a stroke, tumors, blood flow, ect

EEG= electroencephalogram

measures electrical activity of the brain (seizures)

Physical exam- inspection, palpation, & auscultation

  • Dyspnea
  • Breath sounds
  • Cough & sputum
  • Chest pain
  • Palpitations

RRR= regular rate & rhythm

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

Computed tomography (CT) scan

  • may be done as follow up
  • better than x-ray
  • May require iv contrast

Echo= echocardiogram

  • ultrasound of the heart
  • provides information about the size, shape, and pumping ability

  EKG or ECG= Electrocardiogram

  • measures electrical activity of the heart

Cardiac catheterization

  • 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

Pulmonary Function Test (PFT)

  • spirometry
  • measure of lung volumes, useful in asthma and COPD   * 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

Esophagogastroduodenoscopy= EGD

  • procedure that examines the esophagus, stomach and duodenum
  • May help locate a GI bleed

Physical exam

  • leg pain, skin abnormalities, edema, hair growth, nails
  • palpate pulses in extremities
  • evaluate joint rotation and reflexes

Doppler ultrasound

  • Quick way to check for problems with blood flow   * DVT= deep vein thrombosis

Microbiology

  • infections in a patient can be called   * urine= urinary tract infection   * lungs= pneumonia   * skin= cellulitis
  • We start antibiotics to help with the infection before we know what bacteria is growing (empiric coverage)
  • Antimicrobial Stewardship = improve how antibiotics are prescribed by clinicians and used by patient
  • Based on microbiology reports   * S= sensitive     * bacteria will be killed by antibiotic   * R= resistant     * bacteria will not be killed by antibiotic

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