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Scribe america > Course 4: Physical Exam COPY > Flashcards

Course 4: Physical Exam COPY Flashcards

1
Q

What is CVA tenderness?

A

Flank tenderness (costovertebral angle tenderness) -tenderness over the kidneys

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2
Q

adj. Black stool color

A

Melanotic

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3
Q

Motor strength: Very mildly weak

A

4/5

neurologic PE

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4
Q

Pale skin

A

Pallor

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5
Q

HSM

A

Hepatosplenomegaly

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6
Q

Scleral icterus

A

Characterized by jaundice

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7
Q

A frame of reference used to describe anatomy and movement

A

Anatomical Position

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8
Q

Complete Benign Exam: Neurological

A

Alert and Oriented, Normal speech

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9
Q

Make sure to document for Code Exam

A

“A full examination is unable to be obtained due to clinical condition”

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10
Q

“Eardrum blocked by earwax”

A

TM obscured by cerumen

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11
Q

Severity scale for Pitting Pedal Edema

A

Trace to 4+

Pitting pedal is 4 syllabals

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12
Q

DDx: Induration

A

Cellulitis

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13
Q

Absent sensation

A

Numbness

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14
Q

What is the difference between laceration and abrasion?

A

Laceration: incision in the skin that typically need sutures Abrasion: scrape of the skin

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15
Q

Extra Exam Findings: Examines the inner-ear

A

TM erythema or bulging

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16
Q

Benign nose exam

A

Normal Nares (or naris)

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17
Q

Contradiction: Normal Speech (2)

A

Aphasia (loss of ability to understand or express speech) vs. Dysarthria (slurred or slow speech that can be difficult to understand)

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18
Q

MAE

A

Moves All Extremities

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19
Q

Flap of skin

A

Avulsion

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20
Q

Why is Midline bony tenderness “worse” than paraspinal tenderness?

A

Bony tenderness (aka vertebral point tenderness) points towards a spinal fracture and therefore concern for a spinal cord injury Paraspinal tenderness points towards muscle pain or strain

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21
Q

Drooping of upper eyelid

A

Ptosis

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22
Q

Contradiction: Cool/hot to touch

A

Warm

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23
Q

What is the medical term for a nostril?

A

Naris

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24
Q

Sucking in of skin around bones of chest between breathing (esp. pediatric)

A

Retractions

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25
Q

What would you guess “TPP” means?

A

Tenderness to Palpation

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26
Q

Spell the medical term for “Hives”

A

Urticaria

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27
Q

Abdomen S and NT

A

Soft and Non-tender

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28
Q

Contradiction: Normal conjunctiva (2)

A

Pale conjunctiva, Conjunctival infection

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29
Q
A
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30
Q

Glasgow Coma Scale

A
  1. Used to assess level of consciousness in trauma pts
  2. (GCS <15)
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31
Q

Without trauma

A

Atraumatic

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32
Q

Tenderness in RUQ sign

A

Murphy’s sign

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33
Q

Benign Exam “No Touch”: Cardiovascular

A

Well perfused

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34
Q

Swollen and inflamed veins in anus or rectum

A

Hemorrhoids

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35
Q

Sign seen when pt asked to hold arms outwards with palms facing upwards

A

Pronator Drift

shark nato, tokyo drift, I dont get either of themso palms up

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36
Q

DMM

A

Dry Mucous Membranes

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37
Q

Decreased sensation

A

Hypoesthesia

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38
Q

Contradiction: Flat/Odd affect, Tearful, Anxious, Depressed, Hypomanic, Poor eye contact

A

Normal affect

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39
Q

Name an instrument a physician may use to closely investigate the eyes>

A

Slit Lamp Woods Lam Ophthalmoscope (aka fundoscopic exam)

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40
Q

A bruise

A

Ecchymosis

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41
Q
A
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42
Q

Cavities

A

Dental Caries

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43
Q

If a patient says their abdomen feels very painful, can you automatically document “abdominal tenderness” in the PE?

A

No. Subjective vs. Objective

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44
Q

When one eye does not move in concert with other

A

EOM palsy

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45
Q

Scale for Deep Tendon Reflexes (DTRs) (and normal)

A

0 to 4+ (2+ normal)

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46
Q

Fail test to stand with feet together and eyes closed

A

Positive Romberg

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47
Q

Blue color

A

Cyanotic

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48
Q

Drowsy

A

Somnolent

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49
Q

Contradiction: Regular Rhythm

A

Irregularly Irregular Rhythm

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50
Q

In the neurological exam what does “normal gait” mean?

A

Walking normally

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51
Q

Benign cardiovascular exam (2)

A

Regular Rate and Rhythm, Heart sounds nl

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52
Q

Like hematoma (Blood or bleeding under the skin due to trauma of any kind; typically black and blue at first, with color changes as healing progresses)

A

Contusion (a region of injured tissue or skin in which blood capillaries have been ruptured; a bruise.)

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53
Q

Extra Exam Findings: “Pounds” on the back

A

CVA tenderness

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54
Q

What is the medical term for “swollen lymph nodes”?

A

Lymphadenopathy

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55
Q

If you saw RRR written in the cardiac exam, what do you think it might mean?

A

Regular Rate and Rhythm

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56
Q

Enlarged liver

A

Hepatomegaly

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57
Q

What is bony tenderness a sign of?

A

Bone Deformity, Fracture or Injury

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58
Q

Enlarged spleen

A

Splenomegaly

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59
Q

Used to assess level of consciousness in trauma pts

A

GCS, Glascow Coma Exam

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60
Q

Document for female genital exam

A

“Female chaperone present”

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61
Q

Contradiction: Pulse/Sensory/Motor deficits

A

Distal CSMT intact

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62
Q

Complete Benign Exam: Skin

A

Dry, No rashes, Warm

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63
Q

Rectum extends outside body

A

Rectal Prolapse

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64
Q

Pulse on neck

A

Carotid Pulse

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65
Q

Sign tested by passively flexing foot backwards

A
  1. Homan’s sign—» listed in PE for DVT
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66
Q

Type of hernia seen in male genital exams

A

Inguinal Hernia

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67
Q

Complete Benign Exam: Constitutional

A

Well developed, well nourished, NAD (no acute distress)

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68
Q

What is scleral icterus and what does it indicate?

A

Yellowing of the eyes, indicates liver failure

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69
Q

3 Peritoneal Signs

A

Voluntary Guarding, Rebound Tenderness, Rigidity

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70
Q

Normal

A

Benign

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71
Q

Catheter left in the bladder

A

Indwelling Catheter

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72
Q

Affect

A

Feeling and emotion

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73
Q

Motor strength: slight contraction, no movement

A

1/5

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74
Q

Bleeding in the eye

A

Hyphema

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75
Q

DDx: Fluctuance

A

Abscess

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76
Q
A
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77
Q

Swollen lymph nodes

A

Cervical lymphadenopathy

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78
Q

Hives

A

Urticaria

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79
Q

What would you document “RUE strength 3/5” under the “neurological” or “Extremities” section of the exam?

A

Neurological

RUE-Right upper extremity

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80
Q

Orifice separating vagina and uterus

A

Cervical os

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81
Q

Match the following condition or disease that is associated with each physical exam finding.

  • psychiatric evaluation
  • meningitis
  • pyelonephritis
  • CHF
  • Bells Palsy
  • Abscess
  • DVT
  • CVA
A
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82
Q

Unequal pupils

A

Anisocoria

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83
Q

Yellow color

A

Jaundice

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84
Q

Tenderness

A

Pain felt on the release of pressure

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85
Q

Complete Benign Exam: Psychiatric

A

Normal affect

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86
Q

Rash of purple spots on skin

A

Purpura

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87
Q

If you documented “NAD” in the constitutional section would you be contraindicating yourself if you wrote “There is mild respiratory distress” in the pulmonary exam?

A

Yes

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88
Q

Benign Exam “No Touch”: Neck

A

Supple

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89
Q

Contradiction: Murmurs, Rubs, Gallops, Extra Systoles

A

Heart Sounds Normal

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90
Q

Swelling of face (esp. with allergic reactions)

A

Angioedema

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91
Q

Condition of Difficulty speaking

A

Dysarthria

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92
Q

Atraumatic

A

Without trauma

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93
Q

Benign Exam “No Touch”: Neurological

A

Alert and Oriented, Normal speech

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94
Q

Contradiction: Retinal detachment, Papilledema, Hyphema (2)

A

Clear anterior chamber, Sharp disc margins

A hyphema is a pooling or collection of blood inside the anterior chamber of the eye (the space between the cornea and the iris)

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95
Q

Contradiction: Somnolent, Obtunded, Unresponsive

A

Alert

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96
Q

Contradiction: Scleral icterus

A

Sclera are anicteric

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97
Q

Not characterized by jaundice

A

Anicteric

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98
Q

OP

A

Oropharynx

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99
Q

Motor Strength: Normal strength

A

5/5

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100
Q

Written as roman numerals

A

Cranial Nerves

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101
Q

Pulse in groin area

A

Femoral Pulse

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102
Q

Condition of Not able to speak

A

Aphasia

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103
Q

Contradiction: PERRL

A

Anisocoria

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104
Q

A mother states her child has been extremely tired and drowsy recently; based on that, can you document “Lethargic” in the child’s PE?

A

NAH

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105
Q

If you document “there is no pronator drift” in the neurological exam, can you also document “No focal neurological deficits”?

A

No because its a contraindication

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106
Q

Involuntary Guarding

A

Rigidity

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107
Q

Raised area of tissue with bruising

A

Contusion

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108
Q

DDx: decreased rectal tone

A

Spinal Cord Injury

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109
Q

Match the following condition or disease that is associated with each physical exam finding.

  • Asthma
  • Otitis Media
  • CHF
  • Afib
  • SBO
  • Diverticulitis
  • Pneumonia
  • Corneal Abrasion
  • cholelithiasis
A
110
Q

Able to be comforted

A

Consolable

111
Q

Extra Exam Findings: Examines the throat

A

Pharyngeal erythema or exudates

112
Q

Benign Exam “No Touch”: Respiratory

A

No respiratory distress

113
Q

RRR

A

Regular Rate and Rhythm

114
Q

Contradiction: Sinus tenderness, Angioedema, Any signs of trauma

A

Atraumatic/Normocephalic (AT/NC)

115
Q

“loose ligaments”

A

Tendon Laxity

116
Q

Complete Benign Exam: ENT

A

Moist mucous membranes

117
Q
A
118
Q

The flow of blood through the body’s blood vessels

A

Perfusion

119
Q

If a patient has pale conjunctiva what does that indicate?

A

Anemia

120
Q
A
121
Q

Benign Exam “No Touch”: Psychiatric

A

Normal affect

122
Q

Earwax

A

Cerumen

123
Q

Extra Exam Findings: Squeezes the calf muscles

A

Calf tenderness

124
Q

Contradiction: Tachypnea, Accessory Muscle Use

A

No respiratory distress

125
Q

What is fluctuance a sign of?

A

Abscess

126
Q

What does a Guaiac positive stool sample diagnose?

A

GI Bleed

127
Q

Motor strength: Unable to overcome resistance

A

3/5

128
Q

Benign neck and cervical spine exam

A

Supple

129
Q

Feeling and emotion

A

Affect

130
Q

Hesitant to talk/respond

A

Pressured Speech

131
Q

Less serious tenderness left and right of spine

A

Paraspinal Tenderness

132
Q

Pulse on wrist

A

Radial Pulse

133
Q

Benign

A

Normal

134
Q

Anisocoria

A

unequal pupils

135
Q

CTA

A

Clear to Auscultation

normal lung exam

136
Q

Anatomical Position

A

A frame of reference used to describe anatomy and movement

137
Q
A
138
Q

3 descriptions of hemorrhoids

A

Internal, External, Thrombosed

thromb-bloodclot in greek

139
Q

Exam Findings: Palpating the Abdomen (4)

A

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

distended-bloated

140
Q

Benign Exam “No Touch”: Extremities

A

No edema

141
Q

Blood in stool

A

Heme positive

142
Q

Contradiction: Normal finger-to-nose, Normal heel-to-chin

A

Dysmetria (a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye)

143
Q

“Crunching” respiratory sound

A

Crepitus

144
Q

Increased warmth

A

Calor

145
Q

Perfusion

A

The flow of blood through the body’s blood vessels

146
Q

Benign Exam “No Touch”: Gastrointestinal

A

Non-distended

147
Q

Complete Benign Exam: Eyes

A

PERRL, EOMI

148
Q

Blood coming out of ears

A

Hemotympanum

149
Q

“Pus leaking”

A

Purulent Drainage

150
Q

What does AT/NC mean?

A

Atraumatic/Normocephalic

151
Q

Contradiction: Suicidal/Homicidal, Hallucinations, Flight of idea, Paranoid

A

Normal judgement

152
Q

GCS

A

Glascow Coma Exam

153
Q

What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician?

A

Female Chaperone Present

154
Q

To describe a runny nose would the doctor use the word “epistaxis” or “rhinorrhea”?

A

Rhinorrhea

155
Q

Contradiction: Alert

A

Somnolent

156
Q

Benign Exam “No Touch”: ENT

A

Moist mucosa

157
Q

Scale for pulse (normal?)

A

0 to 4+ (2+)

158
Q

Document for rectal exam

A

“Female/Male chaperone present”

159
Q

What does DTR stand for?

A

Deep tendon reflex

160
Q

Organ enlargement

A

Organomegaly

161
Q

Organomegaly

A

Organ enlargement

162
Q

Pulse on side of foot

A

Posterior Tibialis (PT) Pulse

163
Q

Contradiction: Mild/Moderate/Severe Tenderness To Palpation (TTP)

A

Soft and Non-tender

164
Q

Swelling behind eye

A

Papilledema

165
Q

Normal General Pediatric Physical Exam (6)

A

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

166
Q

Collection of blood in pocket of nose

A

Septal hematoma

167
Q

EOMI

A

Extraocular Movements Intact

168
Q

Benign Exam “No Touch”: General

A

Well developed, Well nourished, NAD

169
Q

Purulent

A

Pus-like

170
Q

Pulse on top of foot

A

Dorsalis Pedis (DP) Pulse

171
Q

Complete Benign Exam: Extremities

A

No edema, Full ROM

172
Q

Contradiction: Mild/Mod/Severe Distress

A

No Acute Distress

173
Q

Do any patient complaints belong in the PE?

A

No

174
Q

Contradiction: Normal Bimanual Exam (3)

A

Cervical motion tenderness (CMT), Uterine tenderness, Adnexal tenderness (Ovaries)

175
Q

Icterus

A

Yellowing, also known as jaundice

176
Q

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?

A

McBurney’s point tenderness (Appendicitis)

177
Q

Contradiction: Normal RAM (Rapid Alternating Movements)

A

Dysdiadochokinesia

178
Q

Somnolent

A

Responsive to verbal

179
Q

Used for external eye exam (2)

A

Wood’s lamp, Fluorescein

180
Q

Detailed/descriptive speech

A

Tangential Speech

181
Q

Contradiction: Tachycardic, Bradycardic

A

Regular Rate

182
Q

What does PERRL stand for?

A

Pupils are equal round and reactive to light

183
Q

NAD

A

No Acute Distress

184
Q

In the psychiatric exam, what do SI and HI stand for?

A

Suicidal and Homicidal Ideations

185
Q

Abdomen very full

A

Distended

186
Q

Contradiction: Denies illness/symptoms, Non-compliant with treatment

A

Normal insight

187
Q

Benign mouth/throat exam (2)

A

Moist Mucous Membranes, OP Normal

188
Q

Consolable

A

Able to be comforted

189
Q

“swooshing” in neck artery

A

Carotid bruit

190
Q

Contradiction: Jaundice

A

Normal color

191
Q

DDx: Homan’s sign/Palpable cords

A

DVT

192
Q

“Loose associations”

A

Flight of ideas

193
Q

CSMT

A

Circulation, Sensory, Motor, Tendon

194
Q

adj. Lacking teeth

A

Edentulous

195
Q

Neurological scale for trauma pts

A

Glawgow Coma Scale

196
Q

Contradiction: Capillary Refill less than 2 seconds

A

Delayed capillary refill

197
Q

Benign perfusion exam (2)

A

Pulses Equal and Symmetric, Capillary Refill less than 2 seconds

198
Q

GCS scale

A

3-15

199
Q

Erythema

A

Redness

200
Q

What does NAD stand for?

A

No acute distress or disease

201
Q

Inappropriately happy/energetic

A

Hypomanic

202
Q

Rapid, repetitive, and involuntary movement of the eye

A

Nystagmus

203
Q

Yellowing, also known as jaundice

A

Icterus

204
Q

Complete Benign Exam: Respiratory

A

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

205
Q

Instrument used for fundoycopic exam of the internal eye

A

Ophthalmoscope

206
Q

Which of these 2 physical exam findings could a physician appreciate without auscultating the patients lungs: A. No respiratory distress B. No rales

A

No respiratory distress

207
Q
A
208
Q

Extra Exam Findings: Auscultates the abdomen

A

Hyperactive/hypoactive BS

209
Q

PTA (not prior to arrival)

A

Peritonsillar Abscess (biggest concern for pt w/sore throat)

210
Q

Name the rhythm that the physician would hear if the patient was in Afib?

A

Irregularly irregular rhythm

211
Q

Point to the general area of your body that Cranial Nerves (CN) control?

A

Face

212
Q

Pain felt on the release of pressure

A

Tenderness

213
Q

Redness

A

Erythema

214
Q

Enlargement of thyroid

A

Thyromegaly

215
Q

White plaque on tonsils

A

Tonsillar Exudate

216
Q

Name 2 “Peritoneal signs” in the abdominal exam?

A
  1. Guarding 2. Rebound Tenderness 3. Rigidity
217
Q

Is the Glascow Coma Scale (GCS) associated with trauma patients or medical patients?

A

Trauma

218
Q

Contradiction: well developed, well nourished (3)

A

Cachectic, Emaciated, Malnourished

219
Q

Moveable and compressible (on skin)

A

Fluctuance

220
Q

Contradiction: Diminished breath sounds, Wheezes, Rales, Rhonchi

A

Clear to auscultation bilaterally

221
Q

Extra Exam Findings: Touches the wrists

A

Radial pulses

222
Q

Document for male genital exam

A

“Male chaperone present”

223
Q

Benign Exam “No Touch”: Skin

A

Dry, No rashes

224
Q

What section of the neurological exam would you document “Normal Finger-Nose-Finer test” and “Normal-Heel-to-Shin”?

A

Cerebellar/Coordination

225
Q

DDx: Bony tenderness

A

Fx (fracture)

226
Q

Inflammation of walls of lymphatic vessels

A

Lymphangitis

227
Q

Condition of spot hardening on skin

A

Induration

228
Q

Jaw misalignment

A

Malocclusion

229
Q

Normal Neurological Pediatric Physical Exam (3)

A

Alert, Appropriate for Age, Moves All Extremities x 4

230
Q

Small red or purple spot (“tiny red rash”)

A

Petechiae

231
Q

Contradiction: Normal External Genitalia (3)

A

Sores, Lesions, Rashes

232
Q

Alternative name for Heme Positive

A

Guaiac Positive

233
Q

Pus-like

A

Purulent

234
Q

Contradiction: Irregularly Irregular

A

Regular Rhythm

235
Q

Benign Exam “No Touch”: Eyes

A

PERRL

236
Q

In which body system would you document “TM erythema and bulging”?

A

Ears

237
Q

Exam Findings: Auscultating the Lungs (2)

A

Clear to auscultation bilaterally, No wheezes, rales, or rhonchi

238
Q

If the physician checks the pulse on the right wrist and says “the pulses are fine” what would you document in the PE?

A

Right radial pulse is 2+

239
Q

TTP

A

Tenderness To Palpation

240
Q

Contradiction: Cachectic/Emaciated/Malnourished (2)

A

Well developed, Well nourished

241
Q

Which of these is NOT a peritoneal sign? Guarding, Rebound, Tenderness, Rigidity

A

Tenderness

242
Q

Mentally dulled, “out of it”

A

Obtunded

243
Q

More serious tenderness on spine

A

Vertebral Point (Midline) Tenderness

244
Q

DDx: calf tenderness

A

DVT

245
Q

Motor strength: Unable to overcome gravity

A

2/5

246
Q

Hard, thickened palpable vein

A

Palpable cords

247
Q

Contradiction: alert (3)

A

Somnolent, Obtunded, Unresponsive

248
Q

What abdominal exam is indicative of cholecystitis?

A

Murphy’s Sign

249
Q

Exam Findings: Examining the Legs (2)

A

No edema, Distal pulses intact

250
Q
A
  1. McBurney’s point tenderness
  2. Rovsing’s Sign
  3. Obturator Sign
251
Q

Like abrasion seen in elderly

A

Skin Tear

252
Q

Complete Benign Exam: Abdominal

A

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

253
Q

Complete Benign Exam: Cardiovascular

A

Well perfused, RRR, No murmurs, rubs, or gallops, Distal pulses intact

254
Q

Contradiction: Normal cornea (3)

A

Corneal abrasion, corneal ulcerations, fluorescein uptake

255
Q

Swollen inner nose

A

Boggy turbinates

256
Q

Contradiction: EOMI

A

EOM entrapment

257
Q

Complete Benign Exam: Neck

A

Supple, No lymphadenopathy

258
Q

Redness in back of throat

A

Pharyngeal Erythema

259
Q

Decreased rectal tone

A

Rectal laxity

260
Q

BS

A

Bowel Sounds

261
Q

Contradiction: Tangential/Pressure Speech

A

Normal speech

262
Q

What procedure is associated with a laceration by not an abrasion?

A

Laceration Repair, Sutures

263
Q
A
264
Q

Obtunded

A

Responsive to pain

265
Q

Contradiction: Sclera are anicteric

A

Scleral icterus

266
Q

Contradiction: Dry

A

Diaphoretic

267
Q

DDx: Soft tissue tenderness

A

Contusion

268
Q

Motor strength: Flaccid, limp

A

0/5

269
Q

Contradiction: Hypoesthesia, Numbness

A

Sensation intact

270
Q

Swollen tonsils

A

Tonsillar Hypertrophy

271
Q

Exam Findings: Auscultating the Heart (2)

A

RRR, No murmurs, rubs, or gallops

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