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Scribe America > Day 4: Exam Findings > Flashcards

Day 4: Exam Findings Flashcards

1
Q

Normal Finding: General

A

No acute distress, well developed, well nourished

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2
Q

Normal Finding: Eyes

A

PERRL

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3
Q

Normal Finding: ENT

A

moist mucosa

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4
Q

Normal Finding: Neck

A

supple

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5
Q

Normal Finding: Cardiovascular

A

well perfused

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6
Q

Normal Finding: Respiratory

A

no respiratory distress

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7
Q

Normal Finding: Abdominal

A

non-distended

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8
Q

Normal Finding: Extremities

A

no edema

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9
Q

Normal Finding: Skin

A

warm, dry

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10
Q

Normal Finding: Neurological

A

Alert and Oriented. Normal speech

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11
Q

Normal Finding: Psychiatric

A

normal affect

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12
Q

4 actions of a typical physical exam:

A
  1. assessing pt’s external appearance and mental status
  2. auscultating the pt’s heart and lungs
  3. palpating the abdomen
  4. examining the pt’s legs
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13
Q

Normal Finding: Constitutional

A

No acute distress, well developed, well nourished

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14
Q

Normal Finding: Cardiovascular PE

A

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

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15
Q

Normal Finding: Respiratory PE

A

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

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16
Q

Normal Finding: Abdominal PE

A

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

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17
Q

External Inspection

A

No acute distress. Well-developed, well nourished. PERRL. Moist mucosa. Supple neck. No respiratory distress. Skin warm and dry. Alert and oriented. Normal affect.

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18
Q

Auscultating the heart:

A

regular rate and rhythm. No murmers, rubs, or gallops.

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19
Q

Auscultating the lungs:

A

clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

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20
Q

Palpating the abdomen

A

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

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21
Q

Examining the legs

A

No edema. Distal pulses intact.

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22
Q

Extra Exam: Examines throat

A

looking for pharyngeal erythema or exudates

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23
Q

Extra Exam: examines inner ear

A

looking for TM erythema or bulging

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24
Q

Extra Exam: Auscultates the abdomen

A

looking for Hyperactive/Hypoactive bowel sounds

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25
Q

Extra Exam: Touches the wrists

A

looking for Radial pulses

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26
Q

Extra Exam: Squeezes the calf muscles

A

looking for calf tenderness

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27
Q

Extra Exam: “Pounds” on back

A

looking for CVA tenderness

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28
Q

Normal/Abnormal: No acute distress

A

Mild/moderate/severe distress due to pain

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29
Q

Normal/Abnormal: well developed/well nourished

A

Cachectic/Emaciated/Malnourished

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30
Q

Normal/Abnormal: Alert

A

Somnolent, Obtunded, Unresponsive

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31
Q

Normal/Abnormal: Atraumatic/Normocephalic (AT/NC) Head

A

Any signs of trauma, sinus tenderness, angioedema

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32
Q

Normal/Abnormal: Eyes: PERRL

A

Anisocoria (unequal pupils)

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33
Q

Normal/Abnormal: Extra ocular movements intact (EOMI)

A

EOM entrapment

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34
Q

Normal/Abnormal: Sclera are anicteric

A

Scleral icterus

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35
Q

Normal/Abnormal: normal conjunctiva

A

pale conjunctiva, conjunctival injection

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36
Q

Normal/Abnormal: Eyes: clear anterior chamber

A

hyphema

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37
Q

Normal/Abnormal: Eyes: sharp disc margins

A

papilledema

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38
Q

Normal/Abnormal: Eyes: normal cornea

A

Corneal abrasion or ulcerations, fluorescein uptake, foreign body

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39
Q

Normal/Abnormal: Ears: TMs normal

A

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

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40
Q

Normal/Abnormal: Nose: normal nares

A

Epistaxis, Rhinorrhea, Boggy turminates (swollen inner nose), Septal hematoma

41
Q

Normal/Abnormal: Mouth/Throat: moist mucous membranes

A

Dry mucous membranes (DMM)

42
Q

Normal/Abnormal: Mouth/Throat: Oropharynx (OP) normal

A

Pharyngeal erythema, Tonsillar exudate, Tonsillar hypertrophy, Peritonsillar Abscess (PTA)

43
Q

Normal/Abnormal: Mouth/Throat: Normal dentition

A

Edentulous, Dental caries

44
Q

Normal/Abnormal: Neck: supple

A

Nuchal rigidity, Meningismus, Limited ROM; Jugular Venous Distension (JVD); Carotid Bruit; Cervical lymphadenopathy (swollen lymph nodes); Thyromegaly; Vertebral point vs. Paraspinal tenderness

45
Q

Normal/Abnormal: CV: Regular rate

A

Tachycardia (>100 bpm)/ Bradycardia (<60 bpm)

46
Q

Normal/Abnormal: CV: regular rhythm

A

irregularly irregular rhythm

47
Q

Normal/Abnormal: CV: heart sounds normal

A

Murmer (e.g. 2/6 Systolic Ejection Murmer); Gallop or Rubs, Extrasystoles (extra beats)

48
Q

Normal/Abnormal: Pulses equal and symmetric

A

unequal pulses

49
Q

Normal/Abnormal: Capillary refill less than 2 seconds

A

Delayed capillary refill

50
Q

Normal/Abnormal: No respiratory distress

A

Mild/Moderate/Severe respiratory distress

51
Q

Normal/Abnormal: normal respiratory rate

A

Tachypnea (sign of respiratory distress)

52
Q

Normal/Abnormal: normal effort

A

Accessory muscle use (sign of respiratory distress); diminished (quiet) breath sounds

53
Q

Normal/Abnormal: breath sounds equal and clear

A

Wheezes (inspiratory/expiratory); Rales (crackles); Rhonchi

54
Q

Normal/Abnormal: Abd: soft

A

rigid (involuntary guarding)

55
Q

Normal/Abnormal: Abd: non-tender

A

mild/mod/severe tenderness; voluntary guarding

56
Q

Normal/Abnormal: Abd: no peritoneal signs

A

rebound tenderness, rigidity (involuntary guarding)

57
Q

Normal/Abnormal: Abd: normal bowel sounds

A

absent/hypoactive/hyperactive bowel sounds; organomegaly (Hepatomegaly or Splenomegaly)

58
Q

Normal/Abnormal: Abd: non-distended

A

Distended, Positive Murphy’s sign, positive McBurney’s point tenderness, positive Psoa’s sign, positive obturators sign, positive rovsing’s sign

59
Q

Normal/Abnormal: Rectal: Heme negative (Guaiac negative)

A

Heme positive (Guaiac positive)

60
Q

Normal/Abnormal: Brown stool

A

black/melanotic, bright red, dark red, green, yellow, white; hemorrhoids (internal, external, thrombosed), rectal prolapse

61
Q

Normal/Abnormal: Good rectal tone

A

Decreased rectal tone (spinal cord injury)

62
Q

Normal/Abnormal: Female Genital: normal external genetalia

A

adnexal tenderness or mass

63
Q

Normal/Abnormal: female: normal bimanual exam

A

Cervical motion tenderness (CMT); uterine tenderness

64
Q

Normal/Abnormal: female: normal speculum exam; cervical os is closed; no blood or discharge

A

cervical os is open; blood in the vaginal vault; malodorous/thick white discharge

65
Q

Normal/Abnormal: male: circumcised/uncircumcised, normal genital exam

A

testicular tenderness; epididymal tenderness; testicular edema; testicular mass; urethral discharge; inguinal hernia

66
Q

Normal/Abnormal: MS: non-tender

A

bony tenderness (fracture); soft tissue tenderness (contusion); calf tenderness (DVT)

67
Q

Normal/Abnormal: MS: full ROM

A

Decreased ROM 2degree pain

68
Q

Normal/Abnormal: MS: distal CSMT intact (circulation, sensory, motor, tendon)

A

Pulse/sensory/motor deficits/tendon laxity; pitting pedal edema (trace to 4+); palpable cords/Homan’s sign (DVT)

69
Q

Normal/Abnormal: back: non-tender thoracic and lumbar spine

A

Paraspinal tenderness (muscular), Vertebral Point tenderness (spinal injury); CVA tenderness; Midline deformities/step-offs

70
Q

Normal/Abnormal: Skin: warm/normal temp

A

Cool/hot to touch

71
Q

Normal/Abnormal: skin: dry

A

diaphoretic

72
Q

Normal/Abnormal: skin: normal color

A

jaundice, cyanotic, pallor

73
Q

Normal/Abnormal: skin: no rashes

A

urticaria (hives); petechiae/purpura

74
Q

Normal/Abnormal: skin: no signs of infection

A

erythema; increased warmth (calor); induration (cellulitis); fluctuance (abscess); purulent drainage; lymphangitis

75
Q

Normal/Abnormal: skin: atraumatic;intact

A

ecchymosis, contusion, abrasion, laceration, skin tear, avulsion

76
Q

Normal Neuro

A

Alert/oriented 4 (A&Ox4), non-focal neuro exam
sensation intact; motor strength 5/5 and symmetric; DTR’s 2+ and equal; CN II-XII intact; normal cerebellar exam; normal gait

77
Q

Abnormal Neuro: LOC

A

Somnolent, obtunded, unresponsive (to voice or painful stimuli)

78
Q

Abnormal Neuro: Speech

A

aphasia (expressive or receptive), dysarthria

79
Q

Abnormal Neuro: sensation

A

hypoesthesia (decreased sensation), numbness (absent sensation)

80
Q

Abnormal Neuro: motor strength

A

extremity weakness: 0/5 (flaccid) to 4/5 (mildy weak) pronator drift

81
Q

Abnormal Neuro: CN II-XII

A

visual field loss, unequal pupils (anisocoria), EOM palsy, rightward/leftward gaze, facial asymmetry/droop, decreased gag reflex, tongue deviation

82
Q

Abnormal Neuro: reflexes

A

Abnormal DTR’s, upgoing toes (positive Babinski’s)

83
Q

Abnormal Neuro: Cerebellar

A

dysmetria during finger-to-nose or heel-to-shin, positive Romberg, Vertical nystagmus

84
Q

Abnormal Neuro: gait

A

ataxia/unsteady gait

85
Q

Neuro strengths and DTRs

A 
Motor strength Exam: 5/5 normal strength
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
Reflexes Exam: 
0 absent
1+ hypoactive
2+ normal
3+ increased
4+ unsustained clonus
86
Q

Normal/Abnormal: Psych: normal affect

A

flat affect, odd affect, tearful, anxious, depressed, hypomaniac (inappropriately happy/energetic), poor eye contact

87
Q

Normal/Abnormal: psych: normal judgement

A

suicidal/homicidal (w/or w/o plan)
hallucinations (auditory or visual)
flight of ideas (loose associations)
paranoid

88
Q

Normal/Abnormal: psych: normal insight

A

denies illness/symptoms

non-compliant with treatment

89
Q

Normal/Abnormal: psych: normal speech

A

tangential speech

pressured speech

90
Q

Trauma Exam: Head, Eyes, Ears, Nose, oropharynx

A

Head: Battle’s sign, raccoon eyes, periorbital ecchymosis
Eyes: unequal pupils, subconjunctival hemorrhage, hyphema
Ears: hemotympanum
Nose: nasal bone deformity, epistaxis, septal hematoma
oropharynx: malocclusion, dental injury

91
Q

Trauma Exam: Neck, respiratory, abdominal, rectal

A

Neck: vertebral point tenderness, deformities, step-offs
Respiratory: absent breath sounds, splinting, crepitus
Rectal: rectal laxity, decreased rectal tone

92
Q

Trauma Exam: MS, Back, skin, neuro

A

MS: pelvis unstable, bony tenderness, deformities,
Back: vertebral point tenderness, deformities, step-offs
Skin: ecchymosis, laceration, abrasion, skin tear, avulsion
Neuro: Glasgow Coma Scale (GCS < 15)

93
Q

Code Exam: General, Head, Eyes, Oropharynx

A

General: unresponsive
Head: atraumati
Eyes: fixed and dilated
Oropharynx: Airway patent, ETT in place

94
Q

Code Exam: Cardio, Respiratory, Abdominal, MS, Skin, Neuro

A

Cardio: Absent heart sounds, no palpable pulses
Respiratory: no spontaneous respirations, equal with controlled ventilation
Abdominal: distended
MS: no deformities
Skin: pallor, cyanotic, mottles
Neurological: unresponsive, neurological exam limited due to clinical condition

95
Q

Pediatric Normal Exam: General, head, Eyes, ears, Nose, throat

A

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

head: flat fontanel (if <8 mo)
eyes: PERRL, no scleral icterus
ears: nml TMs
throat: moist mucous membranes

96
Q

Pediatric Normal Exam: Neck, Cardiac, Respiratory, abdominal, genital, extremities, skin, neuro

A

Neck: supple, no meningismus

cardic: regular rate and rhythm
respiratory: no distress, clear and equal
abdmonial: soft, no crying or grimacing with palpation
genital: nml external, testicals descended
extremities: FROM
skin: warm, dry, no rash
neurological: alert, appropriate for age, moves all 4 extremities (MAE x 4)

97
Q

Pediatric Abnormals: General, head, eyes, ears, throat, neck

A

general: lethargic, inconsolable, febrile
head: sunken fontanel, bulging fontanel
eyes: scleral icterus
ears: TM erythema, bulging
throat: pharyngeal erythema
neck: lymphadenopathy

98
Q

Pediatric Abnormals: cardiac, respiratory, abdominal, genital, extremities, skin, neurological

A

cardiac: murmur, tachycardia
respiratory: wheezes, stridor, retractions, nasal flaring
abdominal: crying with abdominal palpation
genital: erythema
extremeties: ecchymoses in various stages of healing
skin: rash (diaper rash, eczema)
neurological: post-ictal, somnolent

Scribe America (11 decks)

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