Course 4, Physical Exam Flashcards
If a pt says their abd feels very painful, can you automatically document “abd tenderness” in the physical exam? Why or why not?
No because “tenderness” is determined by the physician
Which physical exam findings could a physician appreciate without auscultating the patient’s lungs
A) no respiratory distress
B) No rales
A.
What does PERRL stand for
Pupils are equal, round, and reactive to light
What does AT/NC mean
Atraumatic/ Normocephalic
What does NAD stand for?
No acute distress
If a patient has pale conjunctiva, what does that indicate?
anemia
What is sclera icterus, and what does it indicate?
Scleral icterus is yellowish pigmentation of the conjunctival membranes over the sclerae. This indicates liver failure.
Name an instrument a physician may use to closely investigate the eyes.
ophthalmoscope, wood’s lamp/ fluorescien
In which body system would you document “TM erythema and bulging”?
Ears
What is the medical term for a nostril?
nares
To describe a “runny nose” would the doctor use the word “epistaxis” or “rhinorrhea”?
rhinorrhea
What would dry mucous membranes indicate?
Dehydration
Why is midline bony tenderness “worse” than paraspinal tenderness?
Paraspinal tenderness refers to the muscle which could indicate something like kidney stones; while midline bony tenderness could indicate spine damage
If you saw RRR written in the cardiac exam, what do you think it might mean? (it is a normal cardiac finding)
Regular Rate and Rhythm- heart sounds normal
If the physician checks the pulse on the right wrist and says “the pulses are fine”, what would you document in the physical exam?
Right radial pulse 2+
Name two “Peritoneal signs” in the abdominal exam
Voluntary Guarding, Rebound Tenderness, Rigidity (involuntary guarding)
What abdominal exam sign is indicative of Cholecystitis?
Murphy’s sign
If the doctor takes 1 finger and presses in a specific spot in the RLQ, what is the name of the finding they are investigating?
McBurney’s point tenderness, used to identify appendicities
Which of these findings is not a peritoneal sign:
guarding, rebound, tenderness, rigidity
tenderness
What would a “Guaiac positive” stool sample diagnose?
blood in the stool, heme positive, GI bleed
What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician?
“female chaperone present”
What is bony tenderness a sign of?
A fracture
What is CVA tenderness?
Costovertebral Angle Tenderness
What is fluctuance a sign of?
An abscess
What is the difference between a laceration and abrasion?
A laceration is a cut or splitting of the skin (size in cm) an abrasion is a scrape
What procedure is associated with a laceration, but not an abrasion?
Lac repair (suture)
What does A&Ox3 mean?
Alert and Oriented person, place, and time
What section of the neurological exam would you document “Normal Finger-Nose-Finger test” and “Normal Heel-to-Shin”?
Cerebellar Exam “Coordination”
What does DTR stand for?
Deep Tendon Reflex
Point to the general area of your body that Cranial Nerves (CN) control
face, head areas
In the neurological exam, what do SI and HI stand for?
Suicidal ideation and Homicidal Ideation
Is the Glascow Coma Scale (GCS) associated with Trauma pts or Medical Pts?
Trauma points (3=lowest, 15=highest)
Would you document “RUE strength 3/5” under the neurological or extremities section of the exam?
neurological
What would you guess “TTP” means? (TTP in the RUQ)
Tender to palpation
A mother states her child has been extremely tired and drowsy recently; based on that, can you document “Lethargic” in the child’s physical exam?
No, lethargic is an extreme condition.
Spell the medical term for “Hives” (allergic reaction rash)
Urticaria
What is the medical term for “Swollen lymph nodes”?
Lymphadenopathy
If you document “There is right prondator drift” in the neurological exam, can you also document “no neurological deficits”?
No, that is a neurological deficit
If you document “NAD” in the constitutional section, would you be contradicting yourself if you wrote “There is mild respiratory distress” in the pulmonary exam?
Yes, NAD= No Acute Distress
Do any of the pt’s complaints belong in the physical exam?
No, only objective observations.
Name the rhythm that the physician would hear if the patient was in Afib
irregularly irregular rhythm
In the neurological exam, what does “Normal gait” mean?
Normal walking
