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Scribe Training > Course 4: Physical Exam > Flashcards

Course 4: Physical Exam Flashcards

1
Q

Benign Exam: Constitutional

A

Well developed, well nourished. No acute distress.

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2
Q

Benign Exam: Eyes

A

PERRL, EOMI

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3
Q

Benign Exam: ENT

A

Moist mucous membranes.

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4
Q

Benign Exam: Neck

A

Supple, no lymphadenopathy.

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5
Q

Benign Exam: Cardiovascular

A

Regular rate and rhythm. No murmurs, rubs, or gallops. Distal pulses intact.

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6
Q

Benign Exam: Respiratory

A

No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

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7
Q

Benign Exam: Abdominal

A

Soft. Non-tender. No guarding, rebound, or rigidity.

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8
Q

Benign Exam: Extremities

A

No edema. Full ROM.

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9
Q

Benign Exam: Skin

A

Warm, dry.

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10
Q

Benign Exam: Neurological

A

Alert and oriented. Normal speech.

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11
Q

Benign Exam: Psychiatric

A

Normal affect.

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12
Q

If the physician examines the throat, they are looking for… (2)

A

pharyngeal erythema or exudates

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13
Q

If the physician examines the inner-ear, they are looking for… (2)

A

TM erythema or bulging

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14
Q

If the physician auscultates the abdomen, they are looking for…

A

hyperactive/hypoactive bowel sounds

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15
Q

If the physician touches the wrist, they are looking for…

A

radial pulses

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16
Q

If the physician squeezes the calf muscles, they are looking for…

A

calf tenderness

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17
Q

If the physician pounds on the back, they are looking for… (2)

A

CVA tenderness

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18
Q

General/Const. Normal Findings: (3)
NAD
Well developed, well nourished
Alert

A

Mild/Mod/Severe Distress
Cachectic/Emaciated/Malnourished
Somnolent (drowsy, respond to name), Obtunded (out of it, respond to pain), Unresponsive (neither)

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19
Q

Head Normal Findings:

Atraumatic/Normocephalic (3)

A

Any signs of trauma
Sinus tenderness
Angioedema (swelling)

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20
Q 
Eyes Normal Findings:
Pupils are Equal, Round, Reactive to Light (PERRL)
Extra Ocular Movements Intact (EOMI)
Sclera are anicteric  (white)
Normal conjunctiva
A

Anisocoria (unequal pupils)
EOM entrapment
Scleral icterus (yellow)
Pale conjunctiva (anemia) or conjunctival infection

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21
Q 
Ears Normal Findings:
Normal TM (4)
A

TM erythema
TM bulging
TM dullness
TM obscured by cerumen (earwax)

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22
Q 
Nose Normal Findings:
Normal nares (4)
A

epistaxis
rhinorrhea
septal hematoma (raised area)
boggy turbinates (swollen inner nose)

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23
Q

Mouth /Throat Normal Findings:
Moist mucous membranes
Oropharynx (back of throat) normal (7)

A 
Dry mucous membranes (DMM)
Dental caries
edentulous (missing teeth)
pharyngeal erythema
tonsillar exudate (plaque on tonsil)
tonsillar hypertrophy (swollen)
peritonsillar abscess (PTA) (pus pocket)
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24
Q

Neck/Cervical Spine Normal Findings:

Supple (5)

A

JVD
Carotid bruit
Cervical lymphadenopathy (swollen lymph nodes)
Vertebral point (midline) v paraspinal tenderness
thyromegaly (thyroid enlargement)

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25
Q

Cardiovascular Normal Findings:

Regular rate and rhythm. Heart sounds normal. (6)

A 
Tachycardia/Bradycardia
Irregularly irregular rhythm
murmur
pleural rub
gallop
extrasystole (extra beat)
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26
Q

Perfusion Normal Findings:

Pulses are equal and symmetric. Capillary refill less than 2 seconds.

A

at risk for rupture

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27
Q

Pulmonary Normal Findings:

No resp distress. Clear to auscultation bilaterally. (7)

A 
Mild/Mod/Severe Distress
Tachypnea
Accessory muscle use
Diminished breath sounds
Wheezes
Rales
Rhonchi
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28
Q

Abdominal Normal Findings:

Soft and non-tender. (4)

A

mild/mod/severe tenderness to palpitation (TTP)
voluntary guarding
rebound tenderness (feel pain when let go of area)
rigidity (involuntary guarding)

29
Q

Detailed Abd Normal Findings:

Normal bowel sounds. No organomegaly. No mass. (6)

A 
absent/hypoactive/hyperactive bowel sounds
organomegaly 
distended
murphy's sign
mcburney's point tenderness
psoa's sign, obturators, rovsing's
30
Q

Rectal Normal Findings:

normal rectal tone. heme neg. (5)

A 
heme pos. 
abnormal stool color
hemorrhoids
rectal prolapse
decreased rectal tone
31
Q 
Female Genital Normal Findings:
Normal external genitalia
Normal bimanual exam (3)
Normal speculum exam
Cervical os is closed
No blood or discharge
A 
sores, lesions, rashes
cervical motion tenderness (CMT)
uterine tenderness
adnexal tenderness (ovaries)
cervical os open
blood in vaginal vault
malodorous/thick white discharge
32
Q

Male Genital Normal Findings:

circumcised/uncircumcised

A 
testicular tenderness
testicular edema
epididymal tenderness
testicular mass
urethral discharge
inguinal hernia
indwelling catheter
33
Q 
Musc./Extremities Normal Findings:
non-tender (3)
full ROM
distal CSMT intact (2)
no edema
no calf tenderness
A 
bony tenderness (fracture)
soft tissue tenderness (contusion)
calf tenderness (DVT)
decreased ROM
pulse/sensory/motor deficits
tendon laxity
pitting pedal edema 
palpable cords/homan's sign
34
Q

Musc. /Back Normal Findings:

non-tender thoracic and lumbar spine

A

CVA tenderness
paraspinal tenderness
vertebral point tenderness
midline deformities/step offs

35
Q 
Skin Normal Findings:
Warm (2)
dry 
normal color (3)
no rashes (2)
A 
cool to touch
hot to touch
diaphoretic
jaundice (yellow)
cyanotic (blue)
pallor
urticaria (hives)
petechiae/ purpura
36
Q

Skin Infection Normal Findings:

no erythema, warmth or drainage (6)

A 
erythema
increased warmth
induration (firmness)
fluctuance
purulent drainage 
lymphangitis (spreading infection)
37
Q

Skin Trauma Normal Findings:

atraumatic, intact

A 
ecchymosis
contusion (bruise w swelling)
abrasion
laceration
skin tear
avulsion (flap of skin)
38
Q 
Neuro Normal Findings:
alert
oriented x4
normal speech (2)
non-focal neuro exam
A 
somnolent
disoriented to (x4)
aphasia
dysarthria (slurred speech)
any abnormal findings
39
Q

Neuro LOC Normal Findings:

A&O x4

A

Somnolent
obtunded
unresponsive

40
Q

Neuro Motor and Sensation
motor strength 5/5 and symmetric (2)
sensation intact (2)

A

extremity weakness
pronator drift
hypoesthesia (dec sensation)
numbness (absent sensation)

41
Q

Neuro Reflexes Normal Findings:
2+ deep tendon reflexes
Babinksi downgoing toes

A

upgoing toes

42
Q

Pediatric Normal PE: General

A

non-toxic, alert, interactive, playful, smiling, crying with tears on exam, quickly consolable

43
Q

Pediatric Normal PE: Head

A

flat fontanel (

44
Q

Pediatric Normal PE: Eyes

A

PERRL. No scleral icterus.

45
Q

Pediatric Normal PE: Ears

A

Nml TMs

46
Q

Pediatric Normal PE: Throat

A

Moist mucous membranes

47
Q

Pediatric Normal PE: Neck

A

Supple. No meningismus

48
Q

Pediatric Normal PE: Cardiac

A

Regular rate and rhythm

49
Q

Pediatric Normal PE: Respiratory

A

No distress. Clear and equal

50
Q

Pediatric Normal PE: Abdominal

A

Soft, no crying or grimacing with palpation

51
Q

Pediatric Normal PE: Genital

A

Nml external, testicles descended

52
Q

Pediatric Normal PE: Extremities

A

FROM

53
Q

Pediatric Normal PE: Skin

A

Warm, dry, no rash

54
Q

Pediatric Normal PE: Neuro

A

Alert. Appropriate for age. Moves all 4 extremities (MAE x4)

55
Q

Pediatric Abnormal PE: General

A

lethargic, inconsolable, febrile

56
Q

Pediatric Abnormal PE: Head

A

Sunken fontanel, bulging fontanel

57
Q

Pediatric Abnormal PE: Eyes

A

scleral icterus

58
Q

Pediatric Abnormal PE: Ears

A

TM erythema, bulging

59
Q

Pediatric Abnormal PE: Throat

A

pharyngeal erythema

60
Q

Pediatric Abnormal PE: Neck

A

lymphadenopathy

61
Q

Pediatric Abnormal PE: Cardiac

A

Murmur, tachycardia

62
Q

Pediatric Abnormal PE: Respiratory

A

Wheezes, stridor, retractions, nasal flaring

63
Q

Pediatric Abnormal PE: Abdominal

A

Crying with abd pain

64
Q

Pediatric Abnormal PE: Genital

A

erythema

65
Q

Pediatric Abnormal PE: Extremities

A

Ecchymoses in various stages of healing

66
Q

Pediatric Abnormal PE: Skin

A

rash (diaper rash, eczema)

67
Q

Pediatric Abnormal PE: Neuro

A

post-ictal, somnolent

68
Q 
Neuro Cranial Nerves Normal Findings:
visual field intact
PERRL
EOMI
tongue midline
normal gag reflex
facial symmetry 
facial sensation intact
normal shoulder shrug
A 
visual field loss
unequal pupils
EOM palsy, rightward/leftward gaze
tongue deviation
decreased gag reflex
facial droop, ptosis
hypoesthesia, numbness
unequal shoulder shrug
69
Q 
Neuro Cerebellar Exam Normal Findings:
Normal gait
no nystagmus
normal finger to nose
normal heel to shin
negative Bromberg's
normal RAM (rapid alt movements )
no tremor
A

ataxia (off balance), antalgic (painful walking)
nystagmus (shaking eyes)
dysmetria
positive romberg (stand with feet together)
dysdiadochokinesia
tremor

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