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Scribe > Course 4: Physical Exam > Flashcards

Course 4: Physical Exam Flashcards

1
Q

Benign physical exam: constitutional

A

Well developed, well nourished. No acute distress.

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2
Q

Benign physical exam: Eyes

A

PERRL, EOMI

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3
Q

Benign physical exam: ENT

A

Moist mucous membranes

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4
Q

Benign physical exam: Neck

A

Supple. No lymphadenopathy

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5
Q

Benign physical exam: cardiovascular

A

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

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6
Q

Benign physical exam: respiratory

A

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

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7
Q

Benign physical exam: abdominal

A

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

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8
Q

Benign physical exam: extremities

A

No edema, full ROM

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9
Q

Benign physical exam: skin

A

Dry, no rashes. Warm

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10
Q

Benign physical exam: neurological

A

Alert and oriented. Normal speech

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11
Q

Benign physical exam: psychiatric

A

Normal affect

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12
Q

Physical exam-Basic

A
  1. Looking at the pt
  2. Auscultating the heart
  3. Auscultating the lungs
  4. Palpating the abdomen
  5. Examining the legs
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13
Q

Exam findings: external inspection

A
  1. No acute distress
  2. Well developed
  3. Well nourished
  4. PERRL
  5. Moist mucosa
  6. Supple neck
  7. No respiratory distress
  8. Skin is warm and dry
  9. Alert and oriented.
  10. Normal affect
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14
Q

Exam findings: auscultating the heart

A
  1. Regular rate and rhythm.

2. No murmurs, rubs or gallops.

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15
Q

Exam findings: auscultating the lungs

A
  1. Clear to auscultation bilaterally

2. No wheezes, rales, or rhonchi

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16
Q

Exam findings: palpating the abd

A
  1. Soft
  2. Non-tender.
  3. Non-distended.
  4. No guarding, rebound, or rigidity
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17
Q

Exam findings: examining the legs

A
  1. No edema

2. Distal pulses intact

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18
Q

Exam findings: examines throat

A

Pharyngeal erythema or exudate

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19
Q

Exam findings: examines the inner-ear

A

TM erythema or bulging

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20
Q

Exam findings: auscultates the abd

A

Hyperactive/hypoactive bowel sounds

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21
Q

Exam findings: touches the wrists

A

Radial pulses

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22
Q

Exam findings: squeezes the calf muscles

A

Calf tenderness

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23
Q

Exam findings: “pounds” on the back

A

CVA tenderness

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24
Q

Anatomical Position

A

Standing erect, facing directly forward, feet pointed forward and slightly apart, and arms hanging down at the sides with palms facing forward.

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25
Q

Normal: NAD

A

Abnormal: Mild/moderate/severe distress (due to pain)

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26
Q

Normal: Well developed, well nourished

A

Abnormal: cachectic/emaciated/malnourished

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27
Q

Normal: alert

A

Abnormal: somnolent, obtunded, unresponsive

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28
Q

AT/NC

A

Atraumatic/Normcephalic

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29
Q

Normal: AT/NC

A

Abnormal: any signs of trauma, sinus tenderness, angioedema

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30
Q

Normal: PERRL

A

Abnormal: anisocoria (unequal pupils)

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31
Q

EOMI

A

Extra Ocular Movements Intact

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32
Q

Normal: EOMI

A

Abnormal: EOM entrapment

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33
Q

Normal: Sclera are anicteric

A

Abnormal: Scleral icterus

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34
Q

Normal: Normal conjunctiva

A

Abnormal: Pale conjunctiva, conjunctival injection

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35
Q

Clear anterior chamber Sharp disc margins

A
  1. Retinal detachment
  2. Papilledema
  3. Hyphema
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36
Q

Normal: Cornea

A

Abnormal:

  1. Corneal abrasion or ulcerations
  2. Fluorescein uptake
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37
Q

Normal: TM’s

A

Abnormal:

  1. TM erythema
  2. TM bulging
  3. TM dullness
  4. TM obscured by cerumen (earwax)
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38
Q

Normal: Nares (nostrils, singular: naris)

A

Abnormal:

  1. Epistaxis
  2. Rhinorrhea
  3. Septal hematoma
  4. Boggy turbinates (swollen inner nose)
  5. Nasal deformity
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39
Q

Normal: Moist Mucous Membranes Oropharynx (OP)

A

Abnormal:

  1. Dry Mucous Membranes
  2. Dental Caries
  3. Edentulous
  4. Pharyngeal Erythema
  5. Tonsillar Hypertrophy
  6. Peritonsillar Abscess
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40
Q

DMM

A

Dry Mucous Membranes

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41
Q

PTA

A

Peritonsillar Abscess

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42
Q

Normal neck: supple

A

Abnormal:

  1. JVD
  2. Carotid bruit
  3. Cervical lymphadenopathy (swollen lymph nodes)
  4. Vertebral Point (midline) vs. paraspinal tenderness
  5. Thyromegaly
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43
Q

Normal heart: regular rate and rhythm. Heart sounds normall

A

Abnormal:

  1. Tachycardia/ bradycardia
  2. Irregularly irregular rhythm
  3. Murmur
  4. Extrasystoles (extra beats)
  5. Pleural rub
  6. Gallop
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44
Q

Normal heart: regular rate

A

Abnormal:

tachycardic, bradycardic

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45
Q

Normal heart: regular rhythm

A

Abnormal:

irregularly irregular

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46
Q

Normal heart: heart sounds normal

A

Abnormal:

murmurs, rubs, gallops, extra systoles

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47
Q

Delayed capillary refill: 0

A

Absent

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48
Q

Delayed capillary refill: 1+

A

Barely palpable

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49
Q

Delayed capillary refill: 2+

A

Easily palpable (normal)

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50
Q

Delayed capillary refill: 3+

A

Full

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51
Q

Delayed capillary refill: 4+

A

Bounding/aneurysmal

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52
Q

Normal finding:

No respiratory distress

A

Contradictory finding:

  1. mild/moderate/severe respiratory distress
  2. tachypnea
  3. accessory muscle use
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53
Q

Normal finding:

Clear to auscultation bilaterally

A

Contradictory finding:

  1. diminished breath sounds
  2. wheezes
  3. Rales
  4. Rhonchi
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54
Q

CTAB

A

Clear to Auscultation Bilaterally

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55
Q

TTP

A

Tenderness to Palpation

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56
Q

Abdominal normal finding: soft and non-tender

A

Abnormal finding:

  1. mild/moderate/severe TTP
  2. Voluntary guarding
  3. Rebound tenderness
  4. Rigidity
  5. Murphy’s sign
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57
Q

Normal rectum: normal rectal tone, heme negative

A

Abnormal findings:

  1. Heme positive (Guaiac positive)
  2. Abnormal stool color
  3. Hemorrhoids
  4. Rectal Prolapse
  5. Decreased rectal tone
58
Q

CMT

A

Cervical motion tenderness

59
Q

Normal female: normal external genitalia

A

Abnormal:

Sores, lesions, rashes

60
Q

Normal female: normal bimanual exam

A

Abnormal:
CTM
Uterine tenderness
Adnexal tenderness (ovaries)

61
Q

Normal female: normal speculum exam cervical Os is closed no blood or discharge

A

Abnormal:
Cervical Os is open Blood in the vaginal vault
Malodorous/thick white discharge

62
Q

Normal male: normal genital exam circumcised/uncircumcised

A

Abnormal:

  1. Testicular tenderness
  2. Epididymal tenderness
  3. Testicular edema
  4. Testicular mass
  5. Urethral discharge
  6. Inguinal hernia
  7. Indwelling catheter
63
Q

normal muskuloskeletal extremities: non-tender

A

Abnormal:
Bone tenderness
soft tissue tenderness
calf tenderness

64
Q

normal musculoskeletal extremities: full ROM

A

Abnormal:

Decreased ROM 2nd degree pain

65
Q

normal musculoskeletal extremities: Distal CSMT intact

A

Abnormal:
pulse/sensory/motor deficits
Tendon Laxity

66
Q

CSMT

A

Circulation, Sensory, Motor, Tendon

67
Q

A&Ox4

A 
Alert and oriented to:
person
time
place
situation
68
Q

normal neurological finding: normal speech

A

Abnormal:

aphasia, dysarthria

69
Q

normal neurological finding: alert, Ox4

A

Abnormal:

obtunded

70
Q

Strength: Normal strength 5/5

A 
Abnormal:
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
71
Q

Motor normal finding:

sensation intact

A

Abnormal:

Hypoesthesia (decreased sensation)

72
Q

Motor Strengths

A
  1. Pronator Drift
  2. Upper Extremity Strength “Grip strengths”
  3. Lower extremity strengths
73
Q

Deep tendon reflexes

A 
0 Absent
1+ Hypoactive
2+ Normal
3+ Increased
4+ Unsustained clonus
74
Q

Babinski: normal

A

Downgoing toes

75
Q

Babinski: abnormal

A

Upgoing toes

76
Q

Neurological normal findings:

A
  1. Visual field intact
  2. PERRL
  3. EOMI
  4. Tongue midline
  5. Normal gag reflex
  6. Facial symmetry
  7. Facial sensation intact
  8. Normal shoulder shrug
77
Q

Neurological abnormal findings:

A
  1. Visual field loss
  2. Unequal pupils (anisocoria)
  3. EOM palsy, rightward/leftward gaze
  4. Tongue deviation
  5. Decreased gag reflex
  6. Facial droop, ptosis
  7. Hypoesthesia, numbness
  8. Unequal shoulder shrug
78
Q

Normal cerebral exam: normal gait

A

Abnormal finding:

ataxia, antalgic

79
Q

Normal cerebral exam: no nystagmus

A

Abnormal finding:

nystagmus

80
Q

Normal cerebral exam: normal finger-to-nose normal heel-to-shin

A

Abnormal finding:

dysmetria

81
Q

Normal cerebral exam: negative Romberg’s

A

Abnormal:

Positive Romberg

82
Q

Normal cerebral exam: normal RAM

A

Abnormal:

dysdiadochokinesia

83
Q

Normal cerebral exam: no tremor

A

Abnormal:

tremor

84
Q

RAM

A

Rapid Alternating Movements

85
Q

Normal (psychiatric): normal affect

A

Abnormal

  • Flat affect
  • Odd affect
  • Tearful
  • Anxious
  • Depressed
  • Hypomanic
  • Poor eye contact
86
Q

Normal (psychiatric): normal judgment

A

Abnormal:

  • Suicidal/Homicidal
  • Hallucinations
  • Flight of ideas
  • Paranoid
87
Q

Normal (psychiatric): normal insight

A

Abnormal:

  • Denies illness/ symptoms
  • Non-compliant with treatment
88
Q

Normal (psychiatric): normal speech

A

Abnormal:

  • Tangential speech
  • Pressured speech
89
Q

Trauma exam: head

A

Abnormal findings:

  • Battle’s sign
  • Raccoon eyes
  • Periorbital ecchymosis
90
Q

Trauma exam: eyes

A

Abnormal findings:

  • unequal pupils
  • subconjunctival hemorrhage
  • hyphema
91
Q

Trauma exam: ears

A

Abnormal findings:

hemotympanum

92
Q

Trauma exam: nose

A

Abnormal findings:

  • nasal bone deformity
  • epistaxis
  • septal hematoma
93
Q

Trauma exam: oropharynx

A

Abnormal findings:

  • malocclusion
  • dental injury
94
Q

Trauma exam: neck

A

Abnormal findings:

  • vertebral point tenderness
  • deformities
  • step-offs
95
Q

Trauma exam: respiratory

A

Abnormal findings:

  • absent breath sounds
  • splinting
  • crepitus
96
Q

Trauma exam: abd

A

Abnormal findings:

  • tenderness
  • distended
  • ecchymoses
97
Q

Trauma exam: rectal

A

Abnormal findings:

-rectal laxity (decreased rectal tone)

98
Q

Trauma exam: musculoskeletal

A

Abnormal findings:

  • pelvis unstable
  • bony tenderness
  • deformity
99
Q

Trauma exam: back

A

Abnormal findings:

  • vertebral point tenderness
  • deformities
  • step-offs
100
Q

Trauma exam: skin

A

Abnormal findings:

  • ecchymosis
  • laceration
  • abrasion
  • skin tear
  • avulsion
101
Q

Trauma exam: neurological

A

Abnormal findings:

-Glasgow Coma Scale (GCS

102
Q

GCS

A

Glasgow Coma Scale. Used to assess level of consciousness in trauma pts

103
Q

Code exam: general

A

Common finding:

unresponsive

104
Q

Code exam: head

A

Common finding:

  • normcephalic
  • atraumatic
105
Q

Code exam: eyes

A

Common finding:

-fixed and dilated

106
Q

Code exam: oropharynx

A

Common finding:

  • airway patent
  • ETT in place
107
Q

Code exam: cardiovascular

A

Common finding:

  • absent heart sounds
  • no palpable pulses
108
Q

Code exam: respiratory

A

Common finding:

  • no spontaneous respirations
  • equal with controlled ventilation
109
Q

Code exam: abd

A

Common finding:

-distended

110
Q

Code exam: musculoskeletal

A

Common finding:

-no deformities

111
Q

Code exam: skin

A

Common finding:

  • pallor
  • cyanotic
  • mottled
112
Q

Code exam: neurological

A

Common finding:

  • unresponsive
  • neurological exam limited due to clinical condition
113
Q

Pediatric physical exam: general

A

Normal:

  • non-toxic
  • alert
  • interactive
  • playful
  • smiling
  • crying with tears on exam
  • quickly consolable
114
Q

Pediatric physical exam: head

A

Normal:

-flat fontanel (if less than 8 months old)

115
Q

Pediatric physical exam: eyes

A

Normal:

  • PERRL
  • no scleral icterus
116
Q

Pediatric physical exam: ears

A

Normal:

Nml TMs

117
Q

Pediatric physical exam: throat

A

Normal:

Moist mucous membranes

118
Q

Pediatric physical exam: neck

A

Normal:

  • supple
  • no meningitis
119
Q

Pediatric physical exam: cardiac

A

Normal:

-regular rate and rhythm

120
Q

Pediatric physical exam: respiratory

A

Normal:

  • no distress
  • clear and equal
121
Q

Pediatric physical exam: abd

A

Normal:

  • soft
  • no crying or grimacing with palpation
122
Q

Pediatric physical exam: genital

A

Normal:

  • Nml external
  • testicles descended
123
Q

Pediatric physical exam: extremities

A

Normal:

-FROM

124
Q

Pediatric physical exam: skin

A

Normal:

  • warm
  • dry
  • no rash
125
Q

Pediatric physical exam: neurological

A

Normal:

  • alert
  • appropriate for age
  • moves all 4 extremities
126
Q

MAEx4

A

Moves All 4 Extremities

127
Q

Pediatric abnormal: general

A
  • lethargic
  • inconsolable
  • febrile
128
Q

Pediatric abnormal: head

A
  • sunken fontanel

- bulging fontanel

129
Q

Pediatric abnormal: eyes

A

-scleral icterus

130
Q

Pediatric abnormal: ears

A
  • TM erythema

- bulging

131
Q

Pediatric abnormal: throat

A

-pharyngeal erythema

132
Q

Pediatric abnormal: neck

A

-lymphadenopathy

133
Q

Pediatric abnormal: cardiac

A
  • murmur

- tachycardia

134
Q

Pediatric abnormal: respiratory

A
  • wheezes
  • stridor
  • retractions
  • nasal flaring
135
Q

Pediatric abnormal: abd

A

-crying with abd palpation

136
Q

Pediatric abnormal: genital

A

-erythema

137
Q

Pediatric abnormal: extremities

A

-ecchymoses in various stages of hearing

138
Q

Pediatric abnormal: skin

A

-rash

139
Q

Pediatric abnormal: neurological

A
  • post-ictal

- somnolent

140
Q

Tenderness

A

Pain felt on the release of pressure

141
Q

Icterus

A

Yellowing, also known as jaundice

142
Q

Perfusion

A

The flow of blood through the body’s blood vessels

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