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Class 4 Flashcards

1
Q

What is included in the objective portion of the chart?

A

healthcare provider’s observations

diagnostic tests

vital signs

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2
Q

What are elements of the PE?

A

inspection (looking)

palpation (feeling)

auscultation (listening)

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3
Q

What is the only thing that belongs in the PE portion of the chart?

A

only things that the physician saw, heard, felt or smelled

should not include any subjective information or PMHx

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4
Q

Front

A

anterior

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5
Q

Back

A

posterior

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6
Q

near point of attachment

A

proximal

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7
Q

far from point of attachment

A

distal

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8
Q

near midline

A

midal

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9
Q

far from midline

A

lateral

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10
Q

above

A

superior

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11
Q

below

A

inferior

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12
Q

one area

A

focal

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13
Q

widespread

A

diffuse

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14
Q

palm of hand

A

palmar

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15
Q

sole of foot

A

plantar

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16
Q

surface

A

superficial

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17
Q

What is the physical exam grouped by?

A

body systems

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18
Q

What are the 5 vital signs?

A

BP, HR (pulse rate), RR, T, SaO2 (SpO2)

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19
Q

What are abnormal pulse rates?

A

Bradycardic (below 60 bpm)

Tachycardic (above 100 bpm)

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20
Q

What are abnormal RR?

A

Bradypneic (below 12 bpm)

Tachypneic (above 18 bpm)

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21
Q

Constitutional meanig

A

the general appearance of patient

these findings are typically appreciated without touching the patient

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22
Q

What would contradict “alert” ?

A

somnolent, obtunded, unresponsive

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23
Q

What would contradict “well developed, well nourished” ?

A

Cachectic, emaciated, malnourished

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24
Q

What is being invesitgated in constitutional part of PE?

A

distress level, general appearance, smell

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25
Q

What is being investigated in eye portion of PE?

A

pupils, sclera, conjunctiva, movement

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26
Q

What is being investigated in ENT portion of PE?

A

outer ear, inner ear, nares, dentition, oropharnyx

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27
Q

How do you examine the inner ear?

A

use an ophthalmoscope

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28
Q

What is sclera?

A

the white of eye

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29
Q

What is being investigated in neck portion of PE?

A

lympth nodes, thyroid, carotid artery, jugular vein, vertebrae, muscles

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30
Q

What is being investigated in cardiovascular portion of PE?

A

rate and rhythmn (assessed with stethoscope)

pulses

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31
Q

What is being assessed in pulmonary portion of the exam?

A

Respiratory distress, breath sounds

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32
Q

What is being investigated in GI portion of PE?

A

Tenderness, enlarged organs, bowel sounds

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33
Q

What is being assessed in GU portion of PE?

A

masses, skin or mucosal findings, bleeding

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34
Q

What is being assessed in musculoskeletal portion of PE?

A

bones or muscle tenderness, deformity, range of motionn

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35
Q

What is being assessed in skin portion of the PE?

A

rashes, infections, trauma

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36
Q

What is being assessed in lymphatic portion of PE?

A

lymph node

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37
Q

What is being assessed in neurological portion of PE?

A

mental stautes, alertness, speech, vision, coordination, memory

38
Q

What is being assessed in psychological portion of PE?

A

behavior, mood and affect

39
Q

What is a normal status for pupils?

A

PERRL (pupils equal, round and reactive to light)

40
Q

What is an abnormal status for pupils?

A

fixed and dilated

41
Q

What is a normal status for eye movement?

42
Q

What is an abnormal status for eye movement?

43
Q

What is normal for sclerae?

A

sclerae anicteric

44
Q

What is abnormal for sclerae?

A

scleral icterus

45
Q

What does scleral icterus indicate?

A

liver failure

46
Q

What is normal for conjunctiva?

A

normal conjunctiva

47
Q

What is abnormal for conjunctiva?

A

pale, conjunctival injection, subconjunctival hemorrhage, discharge or crusting

48
Q

What is normal for tympanic membranes?

A

TMs normal

49
Q

What is abnormal for tympanic membraes?

A

anything other than TM normal

50
Q

What 3 things are normal for the nose?

A

no discharge, normal nasal mucosa, no active bleeding

51
Q

What is not normal for nasal mucosa?

A

boggy turbinates / swelling of the nasal mucosa

52
Q

What does the suffix -itis mean?

A

inflammation

53
Q

What is normal for the throat and mouth?

A

moist mucous membranes, oropharnyx normal, normal dentition

54
Q

What is abnormal for the oropharnyx?

A

pharyngeal erythema, exudates, tonsillar hypertrophy, tonsillar asymmetry, uvular shift

55
Q

What is abnormal for dentition?

A

edentulous (no teeth), dental caries (cavities)

56
Q

What is normal for the neck?

A

supple, no meningismus, no tenderness, no cervical lymphadenopathy, no jugular vein distension, no thyromegaly, no carotid bruit

57
Q

What is abnormal for meningismus?

A

positive Brudzinski’s sign which indicates meningitis

58
Q

What is abnormal for tenderness of the neck?

A

vertebral point (fracture), paraspinal tenderness (muscle strain)

59
Q

What is an abnormal rhythm for cardiovascular?

A

irregularly irregular rhythm

60
Q

What is opposite of normal heart sounds?

A

murmurs, rubs, and gallops

61
Q

What is normal for pulses?

A

2+ (easily palpable / normal)

Capillary refill less than 2 seconds

62
Q

Where can pulses be found?

A

carotid, radial, femoral, dorsalis pedis, posterior tibial

63
Q

Carotid

64
Q

radial

65
Q

femoral

66
Q

dorsalis pedis

A

top of foot

67
Q

posterior tibial

A

back of the ankle

68
Q

What is normal for respiratory portion of PE?

A

no respiratory distress, clear to auscultation bilaterally

69
Q

What is abnormal to respiratory distress?

A

respiratory distress, tachypnea, accessory muscle use, pursed lip breathing

70
Q

What is abnormal to “clear to auscultation bilaterally” ?

A

diminished breath sounds, wheezes, rales (crackles), rhonchi

71
Q

What is normal for GI portion of PE?

A

soft, nontender, negative Murphy’s sign, negative McBurney’s point tenderness, normal bowel sounds, no organomegaly, no masses

72
Q

What is opposite of soft abdomen

73
Q

What are the four regions of the abdomen?

A

RUQ, LUQ, RLQ, LLQ

74
Q

What does a positive Murphy’s sign indicate?

A

cholecystitis

75
Q

Where do you palpate for Murphy’s sign?

76
Q

What does a positive McBurney’s point tenderness indicate?

A

appendicitis

77
Q

What is the opposite of no organomegaly?

A

hepatomegaly, splenomegaly

78
Q

What is normal for musculoskeletal portion of PE?

A

no tenderness, no edema, normal ROM, distal CSMT intact

79
Q

What is normal for the skin portion of PE?

A

warm, dry, normal color, no rashes, no induration, no fluctuance

80
Q

What is the opposite of dry skin?

A

diaphoretic

81
Q

What is the opposite of normal color skin?

A

Juandice, cyanotic, pallor

82
Q

What does pallor skin indicate?

83
Q

What does cyanotic skin indicate?

84
Q

What is the opposite of no rashes?

A

Urticaria / Wheals

Petechiae

85
Q

What is normal for neurological exam?

A

Alert and oriented x4, speech, motor strength 5/5 and symmetric, sensation intact, reflexes 2+ and symmetric

86
Q

How should reflexes be?

A

2+ and symmetric

87
Q

What is abnormal sensation?

A

Hypoesthesia, numbness

88
Q

What is normal for motor strength?

A

5/5 and symmetric

89
Q

What is pronator drift?

A

one arm dips lower than the other when holding them up

90
Q

What is abnormal for alertness?

A

somnolent, confused, responsive to voice, responsive to painful stimuli, unresponsive to voice or pain

91
Q

What are the four things that we measure orientation to?

A

person, place, time or situation

92
Q

What is abnormal for speech?

A

aphasia, dysarthria

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