ED 4 Flashcards
1
Q
Physical Exam
A
When clinician evaluates each body system by inspection, palpatations, and ausculiation
2
Q
Why is physical exam important?
A
It allows the provider to narrow down the cause
3
Q
What’s the scribes responsability?
A
Documenting the physical exam as the provider performs it.
4
Q
Do you need to be taking notes even if the doctor isn’t talking to you?
A
Yes!
5
Q
What belongs in the physical exam?
A
What the provider saw, heard, felt, and smelled
6
Q
What doesn’t belong in the physical exam?
A
Symptoms, Medical History, Diagnoses, Not inspected
7
Q
RUE
A
Right Upper Extremitiy
8
Q
RLE
A
Right Lower Extremity
9
Q
LUE
A
Left Upper Extremity
10
Q
LLE
A
Left Lower Extremity
11
Q
Anterior
A
Front
12
Q
Posterior
A
Back
13
Q
Medial
A
Near midline
14
Q
Superior
A
Above
15
Q
Focal
A
One area
16
Q
Palmar
A
Palm of hand
17
Q
Superficial
A
Closer to exterior
18
Q
Deep
A
Further from exterior
19
Q
Proximal
A
Near point of attachment
20
Q
Distal
A
Far point of attachment
21
Q
Lateral
A
Far from midline
22
Q
Inferior
A
Below
23
Q
Diffuse
A
Widespread
24
Q
Plantar
A
Sole of foot
25
Constitutional
NAD, well developed/well nourished, alert
26
Abnormal Constitutional
Mild/Moderate/Severe Distress due to pain or respiratory difficulty, Cachectic/Emaciated/Malnourished, Somnolent/Obtunded/Unresponsive
27
Eyes
PERRL, EDMI, No nystagmus, scleral anicteric, normal conjuctiva
28
Abnormal Eyes
Fixed and Dilated, EOM entrapment, Nystagmus, Pale conjunctiva/Conjunctival injection, Discharge or crusting
29
Ears
TMs Normal, No canal swelling or tenderness
30
Abnormal Ears
TM erythema/effusion/bulging/dullness/obscured by cerumen, Canal swelling or tenderness
31
Nose
No discharge, Normal nasal mucosa, no active bleeding
32
Abnormal Nose
Clear or yellow discharge, boggy turbinates/swelling of nasal mucosa, site of bleeding identified
33
Throat and Mouth
Moist mucous membrane, oropharynx normal, normal dentition
34
Abnormal Throat and Mouth
Dry mucous membranes, pharyngeal erythmea/exudates/tonsillar hypertrophy/tonsillar asymmetry/uvular shift, edentulous/dental caries/gum tenderness or edema
35
Neck
Normal range of motion, Supple/No meningisums, no tenderness, no cervical lymphadeneopathy, no JVD, no carotid bruit
36
Abnormal Neck
Limited range of motion, nuchal ridgity/meningismus, vertibral point vs. paraspinal tenderness, anterior and/or posterior cervical lymphadenopathy, JVD, carotid bruit
37
Cardiovascular
Regular rate, regular rhythm, heart sounds normal
38
Abnormal Cardiovascular
Tachycardia/Bradycardia, Irregularly irregular rhythm, murmurs/rubs/gallops/extrasytoles
39
Pulses
2+ (easily palpable/normal), capillary refill less than 2 seconds
40
Abnormal Pulses
0/1+/3+/4+, delayed capillary refill
41
Respiratory
No respiratory distress, clear to auscultation bilaterally
42
Abnormal Respiratory
Mild/Moderate/Severe Respiratory Distress, Tachypnea, accessory muscle use, pursed lip breathing, diminished breath sounds, wheezes, rales, rhonchi
43
Gastrointestinal
Soft, nontender, negative Murphy's sign, negative McBurney's point tenderness, normal bowel sounds, no organomeagly
44
Abnormal Gastrointestinal
Rigidity, Mid/Mod/Severe Tenderness, guarding, rebound, rigidity, positive Murphy's sign, positive McBurney's point tenderness, absent/hypoactive/hyperactive bowel sound, hepatomegaly, spenomegaly
45
Genitourinary
46
Musculoskeletal
Nontender T-Spine and L-Spine, no CVA tenderness, no tenderness to the extremities, no edema, normal ROM, Distal CMST
47
Abnormal Musculoskeletal
Paraspinal tenderness, vertibral point tenderness, costovertebral angle tenderness, bony tenderness, soft tissue tenderness, calf tenderness, edema, limited range of motion secondary to pain, pulse/sensory/motor deficits, tendon laxity
48
Skin
Warm, dry, normal color, no rashes, no induration, no fluctuance, no purulent drainage
49
Abnormal Skin
Cool/hot to touch, diaphoretic, jaundice/cyanotic/pallor, Urticaria/wheals/maculopapular rash, Petechiae, induration, fluctuance, purulent drainage
50
Lymphatic
51
Neurological
Alert, oriented x 4, speech, cranial nerves 2-12 intact, motor strength 5/5 and symmetric, sensation intact, reflexes 2+ and symmetric, normal gait, no nystagmus, normal finger to nose / heel to shin, negative romberg's
52
Psychological
53
Average BP
120/80
54
Average Pulse Rate
60-100 bpm
55
Average Respiratory Rate
12-18
56
Temperature
98.6 F
57
SpO2
>96%
58
Hypotensive
Low BP
59
Hypertensive
High BP
60
Bradycardic
Low pulse rate
61
Tachycardic
High pulse rate
62
Bradypneic
Low respiratory rate
63
Tachypneic
High respiratory rate
64
Hypothermic
Low temperature
65
Febrile
High temperature
66
Hypoxic
Low SpO2
67
