Day 4: Exam Findings Flashcards
Normal Finding: General
No acute distress, well developed, well nourished
Normal Finding: Eyes
PERRL – Pupils Equal, Round, Reactive to Light
Normal Finding: ENT
Moist mucosa
Normal Finding: Neck
supple
Normal Finding: Cardiovascular
well perfused
Normal Finding: Respiratory
no respiratory distress
Normal Finding: Abdominal
non-distended
Normal Finding: Extremities
no edema
Normal Finding: Skin
warm, dry
Normal Finding: Neurological
Alert and Oriented. Normal speech
Normal Finding: Psychiatric
normal affect
4 actions of a typical physical exam
- Assessing pt’s external appearance and mental status
- Auscultating the pt’s heart and lungs
- Palpating the abdomen
- Examining the pt’s legs
Normal Finding: Constitutional
No acute distress, well developed, well nourished
Normal Finding: Cardiovascular PE
Regular rate/rhythm. No murmurs, rubs, or gallops. Distal pulses intact.
Normal Finding: Respiratory PE
No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Normal Finding: Abdominal PE
Soft. Non-tender. Non-distended. No guarding, rebound, or rigidity.
External Inspection
No acute distress. Well-developed, well nourished. PERRL. Moist mucosa. Supple neck. No respiratory distress. Skin warm and dry. Alert and oriented. Normal affect.
Auscultating the heart:
regular rate and rhythm. No murmers, rubs, or gallops.
Auscultating the lungs:
clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
Palpating the abdomen
Soft. Non-tender. Non-distended. No guarding, rebound, or rigidity.
Examining the legs
No edema. Distal pulses intact.
Extra Exam: Examines throat
looking for pharyngeal erythema or exudates
Extra Exam: examines inner ear
looking for TM erythema or bulging
Extra Exam: Auscultates the abdomen
looking for Hyperactive/Hypoactive bowel sounds
Extra Exam: Touches the wrists
looking for Radial pulses
Extra Exam: Squeezes the calf muscles
looking for calf tenderness
Extra Exam: “Pounds” on back
looking for CVA tenderness
Normal/Abnormal: No acute distress
Mild/moderate/severe distress due to pain
Normal/Abnormal: well developed/well nourished
Cachectic/Emaciated/Malnourished
Normal/Abnormal: Alert
Somnolent, Obtunded, Unresponsive
Normal/Abnormal: Atraumatic/Normocephalic (AT/NC) Head
Any signs of trauma, sinus tenderness, angioedema
Normal/Abnormal: Eyes: PERRL
Anisocoria (unequal pupils)
Normal/Abnormal: Extra ocular movements intact (EOMI)
EOM entrapment
Normal/Abnormal: Sclera are anicteric
Scleral icterus
Normal/Abnormal: normal conjunctiva
pale conjunctiva, conjunctival injection
Normal/Abnormal: Eyes: clear anterior chamber
hyphema
Normal/Abnormal: Eyes: sharp disc margins
papilledema
Normal/Abnormal: Eyes: normal cornea
Corneal abrasion or ulcerations, fluorescein uptake, foreign body
Normal/Abnormal: Ears: TMs normal
TM erythema, TM bulging, TM dullness, TM obscured by cerumen (earwax)