EHR Tutor Flashcards

Study Notes

Neurological

Patient is alert and oriented with a Glasgow Coma Scale total of 15.
Pupils are equal, round, and reactive to light.
Cranial nerves II-XII are grossly intact.
Oral examination shows intact teeth, moist mucous membranes, no cavities or bleeding.
Patient swallows without difficulty and has symmetrical ears with a left ear piercing.

Breath Sounds

Breathing exhibits a regular rhythm bilaterally, even and unlabored.
No signs of shortness of breath present.
Lung sounds are clear across all lobes both anteriorly and posteriorly.

Respiratory

Patient experiences non-labored breathing without dyspnea, even upon exertion.
Able to lie flat comfortably without tenderness or pain during palpation.
Exhibits upright posture and steady gait; oxygen saturation is at 99%.

Cardiac

Heart sounds S1 and S2 are regular and distinct at all five auscultation locations: Aortic, Pulmonic, Erbs, Tricuspid, and Mitral.
No jugular vein distention or abnormal chest wall movement observed.
Patient's extremities (arms and legs) are warm without edema.
Maintains a normal sinus rhythm.

Peripheral Vascular

Capillary refill time is less than 3 seconds indicating good perfusion.
Pulses are palpable and strong, measured at 75 beats per minute (Carotid and Radial) with additional pulses assessed at Brachial, Femoral, Popliteal, Dorsalis Pedis, and Posterior Tibial.
All pulses are even and described as 2+ in strength.

Integumentary

Skin is intact, warm, dry, and quickly recoils back to normal.
Skin color is appropriate for patient's race; hair is clean and evenly distributed.
Nails are clean, short, with a capillary refill of less than 3 seconds.
Patient has no tattoos or piercings aside from the left ear.

Musculoskeletal

Patient maintains an upright posture with a steady gait.
Muscle strength is rated at 5/5 bilaterally for grasp, dorsiflexion, and plantar flexion.
Symmetry in muscular structure is noted across both upper and lower extremities with no gross deformities.

Gastrointestinal (GI)

Bowel sounds are hypoactive in the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant (RLQ) and hyperactive in the left lower quadrant (LLQ).
Patient reports soft, brown stools that test negative for blood.
Swallowing is reported without difficulty.

Genitourinary (GU)

Patient is continent and voids without discomfort.
Urine is clear, with no odor or cloudiness, and the patient empties the bladder without difficulty.

Description

Test your knowledge with these EHR flashcards focusing on neurological assessments and breath sounds. Each card provides essential definitions that are crucial for understanding patient evaluations in healthcare. Ideal for students and professionals in the medical field.