Course 4: Physical Exam Flashcards
Objective Information
Physical exam, Lab results, Imaging results
What is a physical exam?
Inspection by the physician of patient’s body systems by inspection, palpation, and auscultation
Inspection
Examination by sight
Palpation
Examination by touch
Auscultation
Examination by listening (with a stethoscope)
Why is the physical exam important?
The physical exam allows the physician to investigate patient complaints and narrow down/rule out diagnoses
What is the scribe’s responsibility for the physical exam?
Document all physical exam findings as the physician is performing the exam
What does belong in the physical exam section of the chart
What the physician:
- Saw
- Heard
- Felt
- Smelled
What does not belong in the physical exam section of the chart
- Symptoms
- Medical history
- Diagnoses
- Any component not inspected
Right
Patient’s right side
Left
Patient’s left side
Anterior
Front
Posterior
Back
Proximal
Near point of attachment
Distal
Far from point of attachment
Medial
Near midline
Lateral
Far from midline
Superior
Above
Inferior
Below
Focal
One area
Diffuse
Widespread
Palmar
Palm of hand
Plantar
Sole of foot
Supeficial
On the surface/shallow
Deep
Away from the surface/further into the body
Body Systems
Constitutional, Eyes, ENT (Ears/Nose/Throat), Neck, Cardiovascular, Pulmonary, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Lymphatic, Neurological, Psychological
Vital Signs
Blood Pressure, Heart Rate, Respiratory Rate, Temperature, Oxygen Saturation
Blood Pressure
Normal: 120/80
Low: Hypotensive
High: Hypertensive
Heart Rate
Normal: 60-100 bpm
Low: Bradycardic
High: Tachycardic
Respiratory Rate
Normal: 12-18 breaths per minute
Low: Bradypneic
High: Tachypneic
Temperature
Normal: 98.6 °F
Low: Hypothermic
High: Febrile (above 100.4 °F)
Oxygen Saturation
Normal: > 96%
Low: Hypoxic (< 92%)
Distress Level Normal (Constitutional)
No acute distress (NAD)
Distress Level Abnormal (Constitutional)
Mild/moderate/severe distress due to pain or respiratory difficulty
Distress Level Method of Investigation (Constitutional)
Visual
General Appearance Normal (Constitutional)
Well developed, Well nourished
General Appearance Abnormal (Constitutional)
Cachectic/Emaciated/Malnourished
General Appearance Method of Investigation (Constitutional)
Visual
Awareness Normal (Constitutional)
Alert
Awareness Abnormal (Constitutional)
Somnolent, Obtunded, Unresponsive
Awareness Method of Investigation (Constitutional)
Visual
Pupils Normal (Eyes)
Pupils Equal, Round, and Reactive to Light (PERRL)
Pupils Abnormal (Eyes)
Fixed and dilated → Stroke, tumor, brain injury, congenital
Pupils Method of Investigation (Eyes)
Visual (shines light in patient’s eye)
Extraocular Movements Normal (Eyes)
Extraocular movements intact (EOMI)
Extraocular Movements Abnormal (Eyes)
EOM entrapment
Extraocular Movements Method of Investigation (Eyes)
Visual (has patient track finger)
Nystagmus Normal (Eyes)
No nystagmus
Nystagmus Abnormal (Eyes)
Nystagmus → Inner ear problem, alcohol or drug use, abnormal brain conditions
Nystagmus Method of Investigation (Eyes)
Visual (has patient track finger)
Sclera Normal (Eyes)
Sclerae anicteric
Sclera Abnormal (Eyes)
Scleral icterus → Liver failure
Sclera Method of Investigation (Eyes)
Visual
Conjunctiva Normal (Eyes)
Normal conjunctiva
Conjunctiva Abnormal (Eyes)
Pale conjunctiva → Anemia
Conjunctival injection → Conjunctivitis
Discharge or crusting → Infection
Conjunctiva Method of Investigation (Eyes)
Visual
Tympanic Membrane (TM) Normal (Ears)
Tympanic membranes (TMs) normal
Tympanic Membrane (TM) Abnormal (Ears)
TM erythema, effusion, bulging, dullness → Otitis media
TM obscured by cerumen → Cannot see TM because of earwax
Tympanic Membrane (TM) Method of Investigation (Ears)
Visual (places otoscope in patient’s ear)
Ear Canal Normal (Ears)
No canal swelling or tenderness
Ear Canal Abnormal (Ears)
Canal swelling or tenderness → Otitis externa
Ear Canal Method of Investigation (Ears)
Visual (places otoscope in patient’s ear)
Discharge Normal (Nose)
No discharge
Discharge Abnormal (Nose)
Clear or yellow discharge
Discharge Method of Investigation (Nose)
Visual
Nasal Mucosa Normal (Nose)
Normal nasal mucosa
Nasal Mucosa Abnormal (Nose)
Boggy turbinates/Swelling of the nasal mucosa → Rhinitis
Nasal Mucosa Method of Investigation (Nose)
Visual (places otoscope in patient’s nare(s))
Nose Bleeding Normal (Nose)
No active bleeding
Nose Bleeding Abnormal (Nose)
Site of bleeding identified → Epistaxis
Nose Bleeding Method of Investigation (Nose)
Visual (places otoscope in patient’s nare(s))
Mucous Membranes Normal (Throat and Mouth)
Moist mucous membranes
Mucous Membranes Abnormal (Throat and Mouth)
Dry mucous membranes → Dehydrated
Mucous Membranes Method of Investigation (Throat and Mouth)
Visual (has patient open mouth)
Oropharynx Normal (Throat and Mouth)
Oropharynx normal
Oropharynx Abnormal (Throat and Mouth)
Pharyngeal erythema → Pharyngitis
Exudates → Pharyngitis, tonsillitis
Tonsillar hypertrophy → Tonsillitis
Tonsillar asymmetry → Peritonsillar abscess
Uvular shift → Peritonsillar abscess
Oropharynx Method of Investigation (Throat and Mouth)
Visual (has patient open mouth, usually uses a light)
Dentition Normal (Throat and Mouth)
Normal dentition
Dentition Abnormal (Throat and Mouth)
Edentulous → No teeth
Dental caries → Cavities
Gum tenderness or edema → Infection
Dentition Method of Investigation (Throat and Mouth)
Visual (has patient open mouth, usually uses a light)
Range of Motion Normal (Neck)
Normal range of motion
Range of Motion Abnormal (Neck)
Limited range of motion
Range of Motion Method of Investigation (Neck)
Visual (has patient move neck)
Meningismus Normal (Neck)
Supple; no meningismus
Meningismus Abnormal (Neck)
Nuchal rigidity; meningismus
Meningismus Method of Investigation (Neck)
Visual (has patient move neck)
Tenderness Normal (Neck)
No tenderness
Tenderness Abnormal (Neck)
Vertebral point tenderness → Fracture
Paraspinal tenderness → Muscle strain
Tenderness Method of Investigation (Neck)
Palpates neck
Lymph Nodes Normal (Neck)
No cervical lymphadenopathy
Lymph Nodes Abnormal (Neck)
Anterior and/or posterior cervical lymphadenopathy → Infection
Lymph Nodes Method of Investigation (Neck)
Palpates side of neck
Jugular Vein Distension (JVD) Normal (Neck)
No jugular vein distension (JVD)
Jugular Vein Distension (JVD) Abnormal (Neck)
Jugular vein distension (JVD) → Heart failure
Jugular Vein Distension (JVD) Method of Investigation (Neck)
Visual
Carotid Bruit Normal (Neck)
No carotid bruit
Carotid Bruit Abnormal (Neck)
Carotid bruit → Carotid artery stenosis
Carotid Bruit Method of Investigation (Neck)
Auscultates (places stethoscope to neck)
Rate Normal (Cardiovascular)
Regular rate
Rate Abnormal (Cardiovascular)
Tachycardia (> 100 bpm)
Bradycardia (< 60 bpm)
Rate Method of Investigation (Cardiovascular)
Auscultate (places stethoscope to chest)
Rhythm Normal (Cardiovascular)
Regular rhythm
Rhythm Abnormal (Cardiovascular)
Irregularly irregular rhythm → A fib
Rhythm Method of Investigation (Cardiovascular)
Auscultate (places stethoscope to chest)
Sounds Normal (Cardiovascular)
Heart sounds normal
Sounds Abnormal (Cardiovascular)
Murmurs → 2/6 systolic ejection murmur
Rubs → Pericarditis
Gallops → Ventricular failure or hypertrophy
Extrasystoles
Sounds Method of Investigation (Cardiovascular)
Auscultate (places stethoscope to chest)
Pulses Normal (Cardiovascular)
2+ (easily palpable, normal)
Pulses Abnormal (Cardiovascular)
0 → Absent pulse
1+ → Barely palpable
3+ → Full
4+ → Bounding/aneurysmal
Pulses Method of Investigation (Cardiovascular)
Palpates pulse in a specific location:
- Carotid - Neck
- Radial - Wrist
- Femoral - Groin
- Dorsalis pedis (DP) - Top of the foot
- Posterior tibial (PT) - Back of the ankle
Capillary Refill Normal (Cardiovascular)
Capillary refill less than 2 seconds
Capillary Refill Abnormal (Cardiovascular)
Delayed capillary refill → Decreased blood flow or dehydration
Capillary Refill Method of Investigation (Cardiovascular)
Visual (presses on finger or toes)
Respiratory Distress Normal (Respiratory)
No respiratory distress
Respiratory Distress Abnormal (Respiratory)
Mild/moderate/severe respiratory distress
Tachypnea
Accessory muscle use
Pursed lip breathing → Emphysema
Respiratory Distress Method of Investigation (Respiratory)
Visually
Lung Auscultation Normal (Respiratory)
Clear to auscultation bilaterally
Lung Auscultation Abnormal (Respiratory)
Diminished breath sounds
Wheezes → Asthma or COPD
Rales/crackles → CHF
Rhonchi → Pneumonia
Lung Auscultation Method of Investigation (Respiratory)
Auscultate (places stethoscope to back)
Softness Normal (Gastrointestinal)
Soft
Softness Abnormal (Gastrointestinal)
Rigidity
Softness Method of Investigation (Gastrointestinal)
Palpates abdomen
Tenderness Normal (Gastrointestinal)
Nontender
Tenderness Abnormal (Gastrointestinal)
Mild/moderate/severe tenderness
3 peritoneal signs:
- Guarding
- Rebound
- Rigidity
Tenderness Method of Investigation (Gastrointestinal)
Palpates abdomen
Murphy’s Sign Normal (Gastrointestinal)
Negative Murphy’s sign
Murphy’s Sign Abnormal (Gastrointestinal)
Positive Murphy’s sign → Cholecystitis
Murphy’s Sign Method of Investigation (Gastrointestinal)
Palpates specific place in RUQ
McBurney’s Point Tenderness Normal (Gastrointestinal)
Negative McBurney’s point tenderness
McBurney’s Point Tenderness Abnormal (Gastrointestinal)
Positive McBurney’s point tenderness → Appendicitis
McBurney’s Point Tenderness Method of Investigation (Gastrointestinal)
Palpates McBurney’s point (RLQ)
Bowel Sounds Normal (Gastrointestinal)
Normal bowel sounds
Bowel Sounds Abnormal (Gastrointestinal)
Absent/hypoactive/hyperactive bowel sounds
Bowel Sounds Method of Investigation (Gastrointestinal)
Auscultate (places stethoscope to abdomen)
Organomegaly Normal (Gastrointestinal)
No organomegaly
Organomegaly Abnormal (Gastrointestinal)
Hepatomegaly
Splenomegaly
Organomegaly Method of Investigation (Gastrointestinal)
Palpates abdomen
Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Normal (Musculoskeletal)
Nontender thoracic spine (T-spine) and lumbar spine (L-spine)
Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Abnormal (Musculoskeletal)
Paraspinal tenderness (muscle injury)
Vertebral point tenderness (spinal injury)
Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Method of Investigation (Musculoskeletal)
Palpates specific area of concern
Costovertebral Angle (CVA) Tenderness Normal (Musculoskeletal)
No costovertebral angle (CVA) tenderness
Costovertebral Angle (CVA) Tenderness Abnormal (Musculoskeletal)
Costovertebral angle tenderness → Kidney stone, pyelonephritis
Costovertebral Angle (CVA) Tenderness Method of Investigation (Musculoskeletal)
Palpates specific area of concern
Extremity Tenderness Normal (Musculoskeletal)
No tenderness to the extremities
Extremity Tenderness Abnormal (Musculoskeletal)
Bony tenderness → Fracture
Soft tissue tenderness → Contusion, strain
Calf tenderness → DVT
Extremity Tenderness Method of Investigation (Musculoskeletal)
Palpates specific area of concern
Edema Normal (Musculoskeletal)
No edema
Edema Abnormal (Musculoskeletal)
Edema (trace to 4+) → CHF
Edema Method of Investigation (Musculoskeletal)
Visual and sometimes palpation
Range of Motion (ROM) Normal (Musculoskeletal)
Normal range of motion (ROM)
Range of Motion (ROM) Abnormal (Musculoskeletal)
Limited range of motion (ROM) secondary to pain
Range of Motion (ROM) Method of Investigation (Musculoskeletal)
Visual (has patient move joint)
CMST (Circulation, Sensory, Motor, Tendon) Normal (Musculoskeletal)
Distal CMST intact
CMST (Circulation, Sensory, Motor, Tendon) Abnormal (Musculoskeletal)
Pulse/sensory/motor deficits
Tendon laxity
CMST (Circulation, Sensory, Motor, Tendon) Method of Investigation (Musculoskeletal)
Palpates distally to the specific area of concern
Warmth Normal (Skin/Integumentary)
Warm
Warmth Abnormal (Skin/Integumentary)
Cool to touch
Hot to touch → Febrile/infection
Warmth Method of Investigation (Skin/Integumentary)
Palpates skin
Wetness Normal (Skin/Integumentary)
Dry
Wetness Abnormal (Skin/Integumentary)
Diaphoretic
Wetness Method of Investigation (Skin/Integumentary)
Visual
Color Normal (Skin/Integumentary)
Normal color
Color Abnormal (Skin/Integumentary)
Jaundice (yellow) → Liver failure
Cyanotic (blue) → Hypoxic
Pallor → Anemia
Color Method of Investigation (Skin/Integumentary)
Visual
Rashes Normal (Skin/Integumentary)
No rashes
Rashes Abnormal (Skin/Integumentary)
Urticaria/wheals/maculopapular rash
Petechiae
Rashes Method of Investigation (Skin/Integumentary)
Visual and sometimes palpates skin
Induration/Fluctuance/Purulent Drainage Normal (Skin/Integumentary)
No induration
No fluctuance
No purulent drainage
Induration/Fluctuance/Purulent Drainage Abnormal (Skin/Integumentary)
Induration → Cellulitis
Fluctuance → Abscess
Purulent drainage → Abscess
Induration/Fluctuance/Purulent Drainage Method of Investigation (Skin/Integumentary)
Visual and sometimes palpates skin
Alertness Normal (Neurological)
Alert
Alertness Abnormal (Neurological)
Somnolent (drowsy)
Confused
Responsive to voice
Responsive to painful stimuli
Unresponsive to voice and pain
Alertness Method of Investigation (Neurological)
Converses with patient
Orientation Normal (Neurological)
Oriented x4
Orientation Abnormal (Neurological)
Disoriented to person, place, time, or situation
Orientation Method of Investigation (Neurological)
Asking:
- What’s your name?
- Where are you?
- What year is it?
- Why are you here?
Speech Normal (Neurological)
Speech
Speech Abnormal (Neurological)
Aphasia (expressive or receptive) → CVA
Dysarthria
Speech Method of Investigation (Neurological)
Person is able to speak and understand when spoken to
Cranial Nerves Normal (Neurological)
Cranial nerves 2 to 12 intact
Cranial Nerves Abnormal (Neurological)
Provider will specify; examples of cranial nerve deficits may be visual field loss, unequal pupils, facial droop, EOM palsy, or facial hypoesthesia
Cranial Nerves Method of Investigation (Neurological)
Varies
Motor Strength Normal (Neurological)
Motor strength 5/5 and symmetric
Motor Strength Abnormal (Neurological)
Pronator drift
Grip or lower extremity strength:
- 4/5 = Very mildly weak
- 3/5 = Unable to overcome resistance
- 2/5 = Unable to overcome gravity
- 1/5 = Slight contraction, no movement
- 0/5 = Flaccid, limp
Motor Strength Method of Investigation (Neurological)
Pronator drift - Visual
Grip or lower extremity strength is felt by the physician
Sensation Normal (Neurological)
Sensation intact
Sensation Abnormal (Neurological)
Hypoesthesia (decreased sensation)
Numbness (absent sensation)
Sensation Method of Investigation (Neurological)
Asking patient if it feels normal and the same on both sides
Reflexes Normal (Neurological)
Reflexes 2+ and symmetric
Reflexes Abnormal (Neurological)
0 = Absent
1+ = Hypoactive
3+ = Increased
4+ = Unsustained clonus
Reflexes Method of Investigation (Neurological)
Visual - Uses a rubber mallet to strike different points on the individual’s body and observes the response:
- Tricep
- Bicep
- Brachioradialis
- Patellar
- Achilles
Gait Normal (Neurological)
Normal gait
Gait Abnormal (Neurological)
Ataxia (uncoordinated)
Antalgic (walking to avoid pain)
Gait Method of Investigation (Neurological)
Visual (asks patient to walk)
Nystagmus Normal (Neurological)
No nystagmus
Nystagmus Abnormal (Neurological)
Nystagmus
Nystagmus Method of Investigation (Neurological)
Visual (asks patient to track finger)
Coordination Normal (Neurological)
Normal finger-to-nose
Normal heel-to-shin
Coordination Abnormal (Neurological)
Dysmetria
Coordination Method of Investigation (Neurological)
Visual (asks patient to touch finger to nose)
Visual (asks patient to rub heel down their shin)
Romberg’s Normal (Neurological)
Negative Romberg’s
Romberg’s Abnormal (Neurological)
Positive Romberg’s
Romberg’s Method of Investigation (Neurological)
Visual (asks patient to stand with arms out)
Trauma Exam Head
Battle’s sign, Raccoon eyes, Periorbital ecchymosis
Trauma Exam Eyes
Unequal pupils, Subconjunctival hemorrhage, Hyphema
Trauma Exam ENT
Hemotympanum, Nasal bone deformity, Epistaxis, Septal hematoma, Malocclusion, Dental injury
Trauma Exam Neck
C-collar in place, Vertebral point tenderness, Step-offs
Trauma Exam Pulmonary
Absent breath sounds, Splinting, Crepitus
Trauma Exam Gastrointestinal
Tenderness, Distended, Ecchymoses
Trauma Exam Musculoskeletal
Pelvis unstable, Bony tenderness, Deformities, Vertebral point tenderness, Step-offs
Trauma Exam Skin
Ecchymosis, Laceration, Abrasion, Skin tear, Avulsion
Trauma Exam Neurological
Glasgow Coma Scale (GCS < 15)
Code Exam Constitutional
Unresponsive
Code Exam Head
Normocephalic, Atraumatic
Code Exam Eyes
Fixed and dilated
Code Exam ENT
Airway patent, ETT in place
Code Exam Cardiovascular
Absent heart sounds, No palpable pulses
Code Exam Pulmonary
No spontaneous respirations, Equal with controlled ventilation
Code Exam Musculoskeletal
No deformities
Code Exam Skin
Pallor, Cyanotic, Mottled
Code Exam Neurological
Unresponsive, Neurological exam limited due to clinical condition
Pediatric Exam Constitutional
Non-toxic, Alert, Interactive, Playful, Smiling, Crying with tears on exam, Quickly consolable
Pediatric Exam Head
Flat fontanel (if less than 8 months old)
Pediatric Exam Eyes
PERRL, No scleral icterus
Pediatric Exam ENT
Normal tympanic membranes (TMs), Moist mucous membranes
Pediatric Exam Neck
Supple, No meningismus
Pediatric Exam Cardiovascular
Regular rate and rhythm, No murmurs
Pediatric Exam Pulmonary
No distress, Clear to auscultation bilaterally, No wheezes, No stridor
Pediatric Exam Gastrointestinal
Soft, No crying or grimacing with palpation
Pediatric Exam Musculoskeletal
Full range of motion (FROM)
Pediatric Exam Skin
Warm and dry, No rash
Pediatric Exam Neurological
Alert, Appropriate for age, Moves all 4 extremities
Heme Normal (Rectal)
Heme negative
Heme Abnormal (Rectal)
Heme positive → GI bleed
Heme Method of Investigation (Rectal)
Heme occult test
Stool Color Normal (Rectal)
Brown stool
Stool Color Abnormal (Rectal)
Black/melanotic, red, yellow, white, bright red
Stool Color Method of Investigation (Rectal)
Visual (stool sample)
Hemorrhoids Normal (Rectal)
No hemorrhoids
Hemorrhoids Abnormal (Rectal)
Hemorrhoids (internal, external, thrombosed)
Hemorrhoids Method of Investigation (Rectal)
Palpates rectum
Tone Normal (Rectal)
Normal tone
Tone Abnormal (Rectal)
Decreased rectal tone → Spinal cord injury
Tone Method of Investigation (Rectal)
Palpates rectum
External Genitalia Normal (Female Genitourinary)
Normal external genitalia
External Genitalia Abnormal (Female Genitourinary)
Sores, lesions, rashes
External Genitalia Method of Investigation (Female Genitourinary)
Visual
Tenderness Normal (Female Genitourinary)
No tenderness
Tenderness Abnormal (Female Genitourinary)
Cervical motion tenderness (CMT) → Pelvic inflammatory disease
Uterine tenderness
Adnexal tenderness → Ovarian cysts
Tenderness Method of Investigation (Female Genitourinary)
Bimanual
Cervical Os Normal (Female Genitourinary)
Cervical os is closed
Cervical Os Abnormal (Female Genitourinary)
Cervical os is open
Cervical Os Method of Investigation (Female Genitourinary)
Visual (uses speculum)
Blood/Discharge Normal (Female Genitourinary)
No blood or discharge
Blood/Discharge Abnormal (Female Genitourinary)
Blood in the vaginal vault
Malodorous/thick white discharge
Blood/Discharge Method of Investigation (Female Genitourinary)
Visual (uses speculum)
External Genitalia Normal (Male Genitourinary)
Normal external genitalia
External Genitalia Abnormal (Male Genitourinary)
Sores, lesions, rashes
External Genitalia Method of Investigation (Male Genitourinary)
Visual
Tenderness Normal (Male Genitourinary)
No tenderness
Tenderness Abnormal (Male Genitourinary)
Testicular tenderness
Epididymal tenderness
Tenderness Method of Investigation (Male Genitourinary)
Palpates testicles
Edema Normal (Male Genitourinary)
No edema
Edema Abnormal (Male Genitourinary)
Testicular edema
Edema Method of Investigation (Male Genitourinary)
Visual
Discharge Normal (Male Genitourinary)
No discharge
Discharge Abnormal (Male Genitourinary)
Urethral discharge → Infection
Discharge Method of Investigation (Male Genitourinary)
Visual
Mass Normal (Male Genitourinary)
No mass
Mass Abnormal (Male Genitourinary)
Inguinal hernia
Testicular mass
Mass Method of Investigation (Male Genitourinary)
Palpates testicles and inguinal region
Affect Normal (Psychological)
Normal affect
Affect Abnormal (Psychological)
Odd affect, flat affect, depressed affect
Affect Method of Investigation (Psychological)
Converses with patient
Suicidal/Homicidal Ideation (SI/HI) Normal (Psychological)
No suicidal ideation (SI) or homicidal ideation (HI)
Suicidal/Homicidal Ideation (SI/HI) Abnormal (Psychological)
Suicidal or homicidal with or without plan
Suicidal/Homicidal Ideation (SI/HI) Method of Investigation (Psychological)
Patient states
Hallucinations Normal (Psychological)
No auditory or visual hallucinations
Hallucinations Abnormal (Psychological)
Auditory or visual hallucinations
Hallucinations Method of Investigation (Psychological)
Converses with patient