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ScribeAmerica ED Classroom Training > Course 4: Physical Exam > Flashcards

Course 4: Physical Exam Flashcards

1
Q

Objective Information

A

Physical exam, Lab results, Imaging results

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2
Q

What is a physical exam?

A

Inspection by the physician of patient’s body systems by inspection, palpation, and auscultation

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3
Q

Inspection

A

Examination by sight

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4
Q

Palpation

A

Examination by touch

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5
Q

Auscultation

A

Examination by listening (with a stethoscope)

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6
Q

Why is the physical exam important?

A

The physical exam allows the physician to investigate patient complaints and narrow down/rule out diagnoses

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7
Q

What is the scribe’s responsibility for the physical exam?

A

Document all physical exam findings as the physician is performing the exam

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8
Q

What does belong in the physical exam section of the chart

A

What the physician:

  • Saw
  • Heard
  • Felt
  • Smelled
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9
Q

What does not belong in the physical exam section of the chart

A
  • Symptoms
  • Medical history
  • Diagnoses
  • Any component not inspected
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10
Q

Right

A

Patient’s right side

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11
Q

Left

A

Patient’s left side

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12
Q

Anterior

A

Front

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13
Q

Posterior

A

Back

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14
Q

Proximal

A

Near point of attachment

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15
Q

Distal

A

Far from point of attachment

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16
Q

Medial

A

Near midline

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17
Q

Lateral

A

Far from midline

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18
Q

Superior

A

Above

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19
Q

Inferior

A

Below

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20
Q

Focal

A

One area

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21
Q

Diffuse

A

Widespread

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22
Q

Palmar

A

Palm of hand

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23
Q

Plantar

A

Sole of foot

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24
Q

Supeficial

A

On the surface/shallow

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25
Q

Deep

A

Away from the surface/further into the body

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26
Q

Body Systems

A

Constitutional, Eyes, ENT (Ears/Nose/Throat), Neck, Cardiovascular, Pulmonary, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Lymphatic, Neurological, Psychological

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27
Q

Vital Signs

A

Blood Pressure, Heart Rate, Respiratory Rate, Temperature, Oxygen Saturation

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28
Q

Blood Pressure

A

Normal: 120/80

Low: Hypotensive

High: Hypertensive

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29
Q

Heart Rate

A

Normal: 60-100 bpm

Low: Bradycardic

High: Tachycardic

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30
Q

Respiratory Rate

A

Normal: 12-18 breaths per minute

Low: Bradypneic

High: Tachypneic

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31
Q

Temperature

A

Normal: 98.6 °F

Low: Hypothermic

High: Febrile (above 100.4 °F)

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32
Q

Oxygen Saturation

A

Normal: > 96%

Low: Hypoxic (< 92%)

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33
Q

Distress Level Normal (Constitutional)

A

No acute distress (NAD)

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34
Q

Distress Level Abnormal (Constitutional)

A

Mild/moderate/severe distress due to pain or respiratory difficulty

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35
Q

Distress Level Method of Investigation (Constitutional)

A

Visual

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36
Q

General Appearance Normal (Constitutional)

A

Well developed, Well nourished

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37
Q

General Appearance Abnormal (Constitutional)

A

Cachectic/Emaciated/Malnourished

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38
Q

General Appearance Method of Investigation (Constitutional)

A

Visual

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39
Q

Awareness Normal (Constitutional)

A

Alert

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40
Q

Awareness Abnormal (Constitutional)

A

Somnolent, Obtunded, Unresponsive

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41
Q

Awareness Method of Investigation (Constitutional)

A

Visual

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42
Q

Pupils Normal (Eyes)

A

Pupils Equal, Round, and Reactive to Light (PERRL)

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43
Q

Pupils Abnormal (Eyes)

A

Fixed and dilated → Stroke, tumor, brain injury, congenital

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44
Q

Pupils Method of Investigation (Eyes)

A

Visual (shines light in patient’s eye)

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45
Q

Extraocular Movements Normal (Eyes)

A

Extraocular movements intact (EOMI)

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46
Q

Extraocular Movements Abnormal (Eyes)

A

EOM entrapment

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47
Q

Extraocular Movements Method of Investigation (Eyes)

A

Visual (has patient track finger)

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48
Q

Nystagmus Normal (Eyes)

A

No nystagmus

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49
Q

Nystagmus Abnormal (Eyes)

A

Nystagmus → Inner ear problem, alcohol or drug use, abnormal brain conditions

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50
Q

Nystagmus Method of Investigation (Eyes)

A

Visual (has patient track finger)

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51
Q

Sclera Normal (Eyes)

A

Sclerae anicteric

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52
Q

Sclera Abnormal (Eyes)

A

Scleral icterus → Liver failure

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53
Q

Sclera Method of Investigation (Eyes)

A

Visual

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54
Q

Conjunctiva Normal (Eyes)

A

Normal conjunctiva

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55
Q

Conjunctiva Abnormal (Eyes)

A

Pale conjunctiva → Anemia

Conjunctival injection → Conjunctivitis

Discharge or crusting → Infection

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56
Q

Conjunctiva Method of Investigation (Eyes)

A

Visual

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57
Q

Tympanic Membrane (TM) Normal (Ears)

A

Tympanic membranes (TMs) normal

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58
Q

Tympanic Membrane (TM) Abnormal (Ears)

A

TM erythema, effusion, bulging, dullness → Otitis media

TM obscured by cerumen → Cannot see TM because of earwax

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59
Q

Tympanic Membrane (TM) Method of Investigation (Ears)

A

Visual (places otoscope in patient’s ear)

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60
Q

Ear Canal Normal (Ears)

A

No canal swelling or tenderness

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61
Q

Ear Canal Abnormal (Ears)

A

Canal swelling or tenderness → Otitis externa

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62
Q

Ear Canal Method of Investigation (Ears)

A

Visual (places otoscope in patient’s ear)

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63
Q

Discharge Normal (Nose)

A

No discharge

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64
Q

Discharge Abnormal (Nose)

A

Clear or yellow discharge

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65
Q

Discharge Method of Investigation (Nose)

A

Visual

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66
Q

Nasal Mucosa Normal (Nose)

A

Normal nasal mucosa

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67
Q

Nasal Mucosa Abnormal (Nose)

A

Boggy turbinates/Swelling of the nasal mucosa → Rhinitis

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68
Q

Nasal Mucosa Method of Investigation (Nose)

A

Visual (places otoscope in patient’s nare(s))

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69
Q

Nose Bleeding Normal (Nose)

A

No active bleeding

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70
Q

Nose Bleeding Abnormal (Nose)

A

Site of bleeding identified → Epistaxis

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71
Q

Nose Bleeding Method of Investigation (Nose)

A

Visual (places otoscope in patient’s nare(s))

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72
Q

Mucous Membranes Normal (Throat and Mouth)

A

Moist mucous membranes

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73
Q

Mucous Membranes Abnormal (Throat and Mouth)

A

Dry mucous membranes → Dehydrated

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74
Q

Mucous Membranes Method of Investigation (Throat and Mouth)

A

Visual (has patient open mouth)

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75
Q

Oropharynx Normal (Throat and Mouth)

A

Oropharynx normal

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76
Q

Oropharynx Abnormal (Throat and Mouth)

A

Pharyngeal erythema → Pharyngitis

Exudates → Pharyngitis, tonsillitis

Tonsillar hypertrophy → Tonsillitis

Tonsillar asymmetry → Peritonsillar abscess

Uvular shift → Peritonsillar abscess

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77
Q

Oropharynx Method of Investigation (Throat and Mouth)

A

Visual (has patient open mouth, usually uses a light)

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78
Q

Dentition Normal (Throat and Mouth)

A

Normal dentition

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79
Q

Dentition Abnormal (Throat and Mouth)

A

Edentulous → No teeth

Dental caries → Cavities

Gum tenderness or edema → Infection

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80
Q

Dentition Method of Investigation (Throat and Mouth)

A

Visual (has patient open mouth, usually uses a light)

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81
Q

Range of Motion Normal (Neck)

A

Normal range of motion

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82
Q

Range of Motion Abnormal (Neck)

A

Limited range of motion

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83
Q

Range of Motion Method of Investigation (Neck)

A

Visual (has patient move neck)

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84
Q

Meningismus Normal (Neck)

A

Supple; no meningismus

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85
Q

Meningismus Abnormal (Neck)

A

Nuchal rigidity; meningismus

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86
Q

Meningismus Method of Investigation (Neck)

A

Visual (has patient move neck)

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87
Q

Tenderness Normal (Neck)

A

No tenderness

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88
Q

Tenderness Abnormal (Neck)

A

Vertebral point tenderness → Fracture

Paraspinal tenderness → Muscle strain

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89
Q

Tenderness Method of Investigation (Neck)

A

Palpates neck

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90
Q

Lymph Nodes Normal (Neck)

A

No cervical lymphadenopathy

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91
Q

Lymph Nodes Abnormal (Neck)

A

Anterior and/or posterior cervical lymphadenopathy → Infection

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92
Q

Lymph Nodes Method of Investigation (Neck)

A

Palpates side of neck

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93
Q

Jugular Vein Distension (JVD) Normal (Neck)

A

No jugular vein distension (JVD)

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94
Q

Jugular Vein Distension (JVD) Abnormal (Neck)

A

Jugular vein distension (JVD) → Heart failure

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95
Q

Jugular Vein Distension (JVD) Method of Investigation (Neck)

A

Visual

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96
Q

Carotid Bruit Normal (Neck)

A

No carotid bruit

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97
Q

Carotid Bruit Abnormal (Neck)

A

Carotid bruit → Carotid artery stenosis

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98
Q

Carotid Bruit Method of Investigation (Neck)

A

Auscultates (places stethoscope to neck)

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99
Q

Rate Normal (Cardiovascular)

A

Regular rate

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100
Q

Rate Abnormal (Cardiovascular)

A

Tachycardia (> 100 bpm)

Bradycardia (< 60 bpm)

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101
Q

Rate Method of Investigation (Cardiovascular)

A

Auscultate (places stethoscope to chest)

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102
Q

Rhythm Normal (Cardiovascular)

A

Regular rhythm

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103
Q

Rhythm Abnormal (Cardiovascular)

A

Irregularly irregular rhythm → A fib

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104
Q

Rhythm Method of Investigation (Cardiovascular)

A

Auscultate (places stethoscope to chest)

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105
Q

Sounds Normal (Cardiovascular)

A

Heart sounds normal

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106
Q

Sounds Abnormal (Cardiovascular)

A

Murmurs → 2/6 systolic ejection murmur

Rubs → Pericarditis

Gallops → Ventricular failure or hypertrophy

Extrasystoles

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107
Q

Sounds Method of Investigation (Cardiovascular)

A

Auscultate (places stethoscope to chest)

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108
Q

Pulses Normal (Cardiovascular)

A

2+ (easily palpable, normal)

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109
Q

Pulses Abnormal (Cardiovascular)

A

0 → Absent pulse

1+ → Barely palpable

3+ → Full

4+ → Bounding/aneurysmal

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110
Q

Pulses Method of Investigation (Cardiovascular)

A

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
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111
Q

Capillary Refill Normal (Cardiovascular)

A

Capillary refill less than 2 seconds

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112
Q

Capillary Refill Abnormal (Cardiovascular)

A

Delayed capillary refill → Decreased blood flow or dehydration

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113
Q

Capillary Refill Method of Investigation (Cardiovascular)

A

Visual (presses on finger or toes)

114
Q

Respiratory Distress Normal (Respiratory)

A

No respiratory distress

115
Q

Respiratory Distress Abnormal (Respiratory)

A

Mild/moderate/severe respiratory distress

Tachypnea

Accessory muscle use

Pursed lip breathing → Emphysema

116
Q

Respiratory Distress Method of Investigation (Respiratory)

A

Visually

117
Q

Lung Auscultation Normal (Respiratory)

A

Clear to auscultation bilaterally

118
Q

Lung Auscultation Abnormal (Respiratory)

A

Diminished breath sounds

Wheezes → Asthma or COPD

Rales/crackles → CHF

Rhonchi → Pneumonia

119
Q

Lung Auscultation Method of Investigation (Respiratory)

A

Auscultate (places stethoscope to back)

120
Q

Softness Normal (Gastrointestinal)

A

Soft

121
Q

Softness Abnormal (Gastrointestinal)

A

Rigidity

122
Q

Softness Method of Investigation (Gastrointestinal)

A

Palpates abdomen

123
Q

Tenderness Normal (Gastrointestinal)

A

Nontender

124
Q

Tenderness Abnormal (Gastrointestinal)

A

Mild/moderate/severe tenderness

3 peritoneal signs:

  1. Guarding
  2. Rebound
  3. Rigidity
125
Q

Tenderness Method of Investigation (Gastrointestinal)

A

Palpates abdomen

126
Q

Murphy’s Sign Normal (Gastrointestinal)

A

Negative Murphy’s sign

127
Q

Murphy’s Sign Abnormal (Gastrointestinal)

A

Positive Murphy’s sign → Cholecystitis

128
Q

Murphy’s Sign Method of Investigation (Gastrointestinal)

A

Palpates specific place in RUQ

129
Q

McBurney’s Point Tenderness Normal (Gastrointestinal)

A

Negative McBurney’s point tenderness

130
Q

McBurney’s Point Tenderness Abnormal (Gastrointestinal)

A

Positive McBurney’s point tenderness → Appendicitis

131
Q

McBurney’s Point Tenderness Method of Investigation (Gastrointestinal)

A

Palpates McBurney’s point (RLQ)

132
Q

Bowel Sounds Normal (Gastrointestinal)

A

Normal bowel sounds

133
Q

Bowel Sounds Abnormal (Gastrointestinal)

A

Absent/hypoactive/hyperactive bowel sounds

134
Q

Bowel Sounds Method of Investigation (Gastrointestinal)

A

Auscultate (places stethoscope to abdomen)

135
Q

Organomegaly Normal (Gastrointestinal)

A

No organomegaly

136
Q

Organomegaly Abnormal (Gastrointestinal)

A

Hepatomegaly

Splenomegaly

137
Q

Organomegaly Method of Investigation (Gastrointestinal)

A

Palpates abdomen

138
Q

Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Normal (Musculoskeletal)

A

Nontender thoracic spine (T-spine) and lumbar spine (L-spine)

139
Q

Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Abnormal (Musculoskeletal)

A

Paraspinal tenderness (muscle injury)

Vertebral point tenderness (spinal injury)

140
Q

Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Method of Investigation (Musculoskeletal)

A

Palpates specific area of concern

141
Q

Costovertebral Angle (CVA) Tenderness Normal (Musculoskeletal)

A

No costovertebral angle (CVA) tenderness

142
Q

Costovertebral Angle (CVA) Tenderness Abnormal (Musculoskeletal)

A

Costovertebral angle tenderness → Kidney stone, pyelonephritis

143
Q

Costovertebral Angle (CVA) Tenderness Method of Investigation (Musculoskeletal)

A

Palpates specific area of concern

144
Q

Extremity Tenderness Normal (Musculoskeletal)

A

No tenderness to the extremities

145
Q

Extremity Tenderness Abnormal (Musculoskeletal)

A

Bony tenderness → Fracture

Soft tissue tenderness → Contusion, strain

Calf tenderness → DVT

146
Q

Extremity Tenderness Method of Investigation (Musculoskeletal)

A

Palpates specific area of concern

147
Q

Edema Normal (Musculoskeletal)

A

No edema

148
Q

Edema Abnormal (Musculoskeletal)

A

Edema (trace to 4+) → CHF

149
Q

Edema Method of Investigation (Musculoskeletal)

A

Visual and sometimes palpation

150
Q

Range of Motion (ROM) Normal (Musculoskeletal)

A

Normal range of motion (ROM)

151
Q

Range of Motion (ROM) Abnormal (Musculoskeletal)

A

Limited range of motion (ROM) secondary to pain

152
Q

Range of Motion (ROM) Method of Investigation (Musculoskeletal)

A

Visual (has patient move joint)

153
Q

CMST (Circulation, Sensory, Motor, Tendon) Normal (Musculoskeletal)

A

Distal CMST intact

154
Q

CMST (Circulation, Sensory, Motor, Tendon) Abnormal (Musculoskeletal)

A

Pulse/sensory/motor deficits

Tendon laxity

155
Q

CMST (Circulation, Sensory, Motor, Tendon) Method of Investigation (Musculoskeletal)

A

Palpates distally to the specific area of concern

156
Q

Warmth Normal (Skin/Integumentary)

A

Warm

157
Q

Warmth Abnormal (Skin/Integumentary)

A

Cool to touch

Hot to touch → Febrile/infection

158
Q

Warmth Method of Investigation (Skin/Integumentary)

A

Palpates skin

159
Q

Wetness Normal (Skin/Integumentary)

A

Dry

160
Q

Wetness Abnormal (Skin/Integumentary)

A

Diaphoretic

161
Q

Wetness Method of Investigation (Skin/Integumentary)

A

Visual

162
Q

Color Normal (Skin/Integumentary)

A

Normal color

163
Q

Color Abnormal (Skin/Integumentary)

A

Jaundice (yellow) → Liver failure

Cyanotic (blue) → Hypoxic

Pallor → Anemia

164
Q

Color Method of Investigation (Skin/Integumentary)

A

Visual

165
Q

Rashes Normal (Skin/Integumentary)

A

No rashes

166
Q

Rashes Abnormal (Skin/Integumentary)

A

Urticaria/wheals/maculopapular rash

Petechiae

167
Q

Rashes Method of Investigation (Skin/Integumentary)

A

Visual and sometimes palpates skin

168
Q

Induration/Fluctuance/Purulent Drainage Normal (Skin/Integumentary)

A

No induration

No fluctuance

No purulent drainage

169
Q

Induration/Fluctuance/Purulent Drainage Abnormal (Skin/Integumentary)

A

Induration → Cellulitis

Fluctuance → Abscess

Purulent drainage → Abscess

170
Q

Induration/Fluctuance/Purulent Drainage Method of Investigation (Skin/Integumentary)

A

Visual and sometimes palpates skin

171
Q

Alertness Normal (Neurological)

A

Alert

172
Q

Alertness Abnormal (Neurological)

A

Somnolent (drowsy)

Confused

Responsive to voice

Responsive to painful stimuli

Unresponsive to voice and pain

173
Q

Alertness Method of Investigation (Neurological)

A

Converses with patient

174
Q

Orientation Normal (Neurological)

A

Oriented x4

175
Q

Orientation Abnormal (Neurological)

A

Disoriented to person, place, time, or situation

176
Q

Orientation Method of Investigation (Neurological)

A

Asking:

  • What’s your name?
  • Where are you?
  • What year is it?
  • Why are you here?
177
Q

Speech Normal (Neurological)

A

Speech

178
Q

Speech Abnormal (Neurological)

A

Aphasia (expressive or receptive) → CVA

Dysarthria

179
Q

Speech Method of Investigation (Neurological)

A

Person is able to speak and understand when spoken to

180
Q

Cranial Nerves Normal (Neurological)

A

Cranial nerves 2 to 12 intact

181
Q

Cranial Nerves Abnormal (Neurological)

A

Provider will specify; examples of cranial nerve deficits may be visual field loss, unequal pupils, facial droop, EOM palsy, or facial hypoesthesia

182
Q

Cranial Nerves Method of Investigation (Neurological)

A

Varies

183
Q

Motor Strength Normal (Neurological)

A

Motor strength 5/5 and symmetric

184
Q

Motor Strength Abnormal (Neurological)

A

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
185
Q

Motor Strength Method of Investigation (Neurological)

A

Pronator drift - Visual

Grip or lower extremity strength is felt by the physician

186
Q

Sensation Normal (Neurological)

A

Sensation intact

187
Q

Sensation Abnormal (Neurological)

A

Hypoesthesia (decreased sensation)

Numbness (absent sensation)

188
Q

Sensation Method of Investigation (Neurological)

A

Asking patient if it feels normal and the same on both sides

189
Q

Reflexes Normal (Neurological)

A

Reflexes 2+ and symmetric

190
Q

Reflexes Abnormal (Neurological)

A

0 = Absent

1+ = Hypoactive

3+ = Increased

4+ = Unsustained clonus

191
Q

Reflexes Method of Investigation (Neurological)

A

Visual - Uses a rubber mallet to strike different points on the individual’s body and observes the response:

  • Tricep
  • Bicep
  • Brachioradialis
  • Patellar
  • Achilles
192
Q

Gait Normal (Neurological)

A

Normal gait

193
Q

Gait Abnormal (Neurological)

A

Ataxia (uncoordinated)

Antalgic (walking to avoid pain)

194
Q

Gait Method of Investigation (Neurological)

A

Visual (asks patient to walk)

195
Q

Nystagmus Normal (Neurological)

A

No nystagmus

196
Q

Nystagmus Abnormal (Neurological)

A

Nystagmus

197
Q

Nystagmus Method of Investigation (Neurological)

A

Visual (asks patient to track finger)

198
Q

Coordination Normal (Neurological)

A

Normal finger-to-nose

Normal heel-to-shin

199
Q

Coordination Abnormal (Neurological)

A

Dysmetria

200
Q

Coordination Method of Investigation (Neurological)

A

Visual (asks patient to touch finger to nose)

Visual (asks patient to rub heel down their shin)

201
Q

Romberg’s Normal (Neurological)

A

Negative Romberg’s

202
Q

Romberg’s Abnormal (Neurological)

A

Positive Romberg’s

203
Q

Romberg’s Method of Investigation (Neurological)

A

Visual (asks patient to stand with arms out)

204
Q

Trauma Exam Head

A

Battle’s sign, Raccoon eyes, Periorbital ecchymosis

205
Q

Trauma Exam Eyes

A

Unequal pupils, Subconjunctival hemorrhage, Hyphema

206
Q

Trauma Exam ENT

A

Hemotympanum, Nasal bone deformity, Epistaxis, Septal hematoma, Malocclusion, Dental injury

207
Q

Trauma Exam Neck

A

C-collar in place, Vertebral point tenderness, Step-offs

208
Q

Trauma Exam Pulmonary

A

Absent breath sounds, Splinting, Crepitus

209
Q

Trauma Exam Gastrointestinal

A

Tenderness, Distended, Ecchymoses

210
Q

Trauma Exam Musculoskeletal

A

Pelvis unstable, Bony tenderness, Deformities, Vertebral point tenderness, Step-offs

211
Q

Trauma Exam Skin

A

Ecchymosis, Laceration, Abrasion, Skin tear, Avulsion

212
Q

Trauma Exam Neurological

A

Glasgow Coma Scale (GCS < 15)

213
Q

Code Exam Constitutional

A

Unresponsive

214
Q

Code Exam Head

A

Normocephalic, Atraumatic

215
Q

Code Exam Eyes

A

Fixed and dilated

216
Q

Code Exam ENT

A

Airway patent, ETT in place

217
Q

Code Exam Cardiovascular

A

Absent heart sounds, No palpable pulses

218
Q

Code Exam Pulmonary

A

No spontaneous respirations, Equal with controlled ventilation

219
Q

Code Exam Musculoskeletal

A

No deformities

220
Q

Code Exam Skin

A

Pallor, Cyanotic, Mottled

221
Q

Code Exam Neurological

A

Unresponsive, Neurological exam limited due to clinical condition

222
Q

Pediatric Exam Constitutional

A

Non-toxic, Alert, Interactive, Playful, Smiling, Crying with tears on exam, Quickly consolable

223
Q

Pediatric Exam Head

A

Flat fontanel (if less than 8 months old)

224
Q

Pediatric Exam Eyes

A

PERRL, No scleral icterus

225
Q

Pediatric Exam ENT

A

Normal tympanic membranes (TMs), Moist mucous membranes

226
Q

Pediatric Exam Neck

A

Supple, No meningismus

227
Q

Pediatric Exam Cardiovascular

A

Regular rate and rhythm, No murmurs

228
Q

Pediatric Exam Pulmonary

A

No distress, Clear to auscultation bilaterally, No wheezes, No stridor

229
Q

Pediatric Exam Gastrointestinal

A

Soft, No crying or grimacing with palpation

230
Q

Pediatric Exam Musculoskeletal

A

Full range of motion (FROM)

231
Q

Pediatric Exam Skin

A

Warm and dry, No rash

232
Q

Pediatric Exam Neurological

A

Alert, Appropriate for age, Moves all 4 extremities

233
Q

Heme Normal (Rectal)

A

Heme negative

234
Q

Heme Abnormal (Rectal)

A

Heme positive → GI bleed

235
Q

Heme Method of Investigation (Rectal)

A

Heme occult test

236
Q

Stool Color Normal (Rectal)

A

Brown stool

237
Q

Stool Color Abnormal (Rectal)

A

Black/melanotic, red, yellow, white, bright red

238
Q

Stool Color Method of Investigation (Rectal)

A

Visual (stool sample)

239
Q

Hemorrhoids Normal (Rectal)

A

No hemorrhoids

240
Q

Hemorrhoids Abnormal (Rectal)

A

Hemorrhoids (internal, external, thrombosed)

241
Q

Hemorrhoids Method of Investigation (Rectal)

A

Palpates rectum

242
Q

Tone Normal (Rectal)

A

Normal tone

243
Q

Tone Abnormal (Rectal)

A

Decreased rectal tone → Spinal cord injury

244
Q

Tone Method of Investigation (Rectal)

A

Palpates rectum

245
Q

External Genitalia Normal (Female Genitourinary)

A

Normal external genitalia

246
Q

External Genitalia Abnormal (Female Genitourinary)

A

Sores, lesions, rashes

247
Q

External Genitalia Method of Investigation (Female Genitourinary)

A

Visual

248
Q

Tenderness Normal (Female Genitourinary)

A

No tenderness

249
Q

Tenderness Abnormal (Female Genitourinary)

A

Cervical motion tenderness (CMT) → Pelvic inflammatory disease

Uterine tenderness

Adnexal tenderness → Ovarian cysts

250
Q

Tenderness Method of Investigation (Female Genitourinary)

A

Bimanual

251
Q

Cervical Os Normal (Female Genitourinary)

A

Cervical os is closed

252
Q

Cervical Os Abnormal (Female Genitourinary)

A

Cervical os is open

253
Q

Cervical Os Method of Investigation (Female Genitourinary)

A

Visual (uses speculum)

254
Q

Blood/Discharge Normal (Female Genitourinary)

A

No blood or discharge

255
Q

Blood/Discharge Abnormal (Female Genitourinary)

A

Blood in the vaginal vault

Malodorous/thick white discharge

256
Q

Blood/Discharge Method of Investigation (Female Genitourinary)

A

Visual (uses speculum)

257
Q

External Genitalia Normal (Male Genitourinary)

A

Normal external genitalia

258
Q

External Genitalia Abnormal (Male Genitourinary)

A

Sores, lesions, rashes

259
Q

External Genitalia Method of Investigation (Male Genitourinary)

A

Visual

260
Q

Tenderness Normal (Male Genitourinary)

A

No tenderness

261
Q

Tenderness Abnormal (Male Genitourinary)

A

Testicular tenderness

Epididymal tenderness

262
Q

Tenderness Method of Investigation (Male Genitourinary)

A

Palpates testicles

263
Q

Edema Normal (Male Genitourinary)

A

No edema

264
Q

Edema Abnormal (Male Genitourinary)

A

Testicular edema

265
Q

Edema Method of Investigation (Male Genitourinary)

A

Visual

266
Q

Discharge Normal (Male Genitourinary)

A

No discharge

267
Q

Discharge Abnormal (Male Genitourinary)

A

Urethral discharge → Infection

268
Q

Discharge Method of Investigation (Male Genitourinary)

A

Visual

269
Q

Mass Normal (Male Genitourinary)

A

No mass

270
Q

Mass Abnormal (Male Genitourinary)

A

Inguinal hernia

Testicular mass

271
Q

Mass Method of Investigation (Male Genitourinary)

A

Palpates testicles and inguinal region

272
Q

Affect Normal (Psychological)

A

Normal affect

273
Q

Affect Abnormal (Psychological)

A

Odd affect, flat affect, depressed affect

274
Q

Affect Method of Investigation (Psychological)

A

Converses with patient

275
Q

Suicidal/Homicidal Ideation (SI/HI) Normal (Psychological)

A

No suicidal ideation (SI) or homicidal ideation (HI)

276
Q

Suicidal/Homicidal Ideation (SI/HI) Abnormal (Psychological)

A

Suicidal or homicidal with or without plan

277
Q

Suicidal/Homicidal Ideation (SI/HI) Method of Investigation (Psychological)

A

Patient states

278
Q

Hallucinations Normal (Psychological)

A

No auditory or visual hallucinations

279
Q

Hallucinations Abnormal (Psychological)

A

Auditory or visual hallucinations

280
Q

Hallucinations Method of Investigation (Psychological)

A

Converses with patient

ScribeAmerica ED Classroom Training (5 decks)

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