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Scribe Training > ED 4 > Flashcards

ED 4 Flashcards

1
Q

Physical Exam

A

When clinician evaluates each body system by inspection, palpatations, and ausculiation

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2
Q

Why is physical exam important?

A

It allows the provider to narrow down the cause

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3
Q

What’s the scribes responsability?

A

Documenting the physical exam as the provider performs it.

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4
Q

Do you need to be taking notes even if the doctor isn’t talking to you?

A

Yes!

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5
Q

What belongs in the physical exam?

A

What the provider saw, heard, felt, and smelled

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6
Q

What doesn’t belong in the physical exam?

A

Symptoms, Medical History, Diagnoses, Not inspected

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7
Q

RUE

A

Right Upper Extremitiy

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8
Q

RLE

A

Right Lower Extremity

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9
Q

LUE

A

Left Upper Extremity

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10
Q

LLE

A

Left Lower Extremity

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11
Q

Anterior

A

Front

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12
Q

Posterior

A

Back

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13
Q

Medial

A

Near midline

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14
Q

Superior

A

Above

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15
Q

Focal

A

One area

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16
Q

Palmar

A

Palm of hand

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17
Q

Superficial

A

Closer to exterior

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18
Q

Deep

A

Further from exterior

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19
Q

Proximal

A

Near point of attachment

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20
Q

Distal

A

Far point of attachment

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21
Q

Lateral

A

Far from midline

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22
Q

Inferior

A

Below

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23
Q

Diffuse

A

Widespread

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24
Q

Plantar

A

Sole of foot

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25
Q

Constitutional

A

NAD, well developed/well nourished, alert

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26
Q

Abnormal Constitutional

A

Mild/Moderate/Severe Distress due to pain or respiratory difficulty, Cachectic/Emaciated/Malnourished, Somnolent/Obtunded/Unresponsive

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27
Q

Eyes

A

PERRL, EDMI, No nystagmus, scleral anicteric, normal conjuctiva

28
Q

Abnormal Eyes

A

Fixed and Dilated, EOM entrapment, Nystagmus, Pale conjunctiva/Conjunctival injection, Discharge or crusting

29
Q

Ears

A

TMs Normal, No canal swelling or tenderness

30
Q

Abnormal Ears

A

TM erythema/effusion/bulging/dullness/obscured by cerumen, Canal swelling or tenderness

31
Q

Nose

A

No discharge, Normal nasal mucosa, no active bleeding

32
Q

Abnormal Nose

A

Clear or yellow discharge, boggy turbinates/swelling of nasal mucosa, site of bleeding identified

33
Q

Throat and Mouth

A

Moist mucous membrane, oropharynx normal, normal dentition

34
Q

Abnormal Throat and Mouth

A

Dry mucous membranes, pharyngeal erythmea/exudates/tonsillar hypertrophy/tonsillar asymmetry/uvular shift, edentulous/dental caries/gum tenderness or edema

35
Q

Neck

A

Normal range of motion, Supple/No meningisums, no tenderness, no cervical lymphadeneopathy, no JVD, no carotid bruit

36
Q

Abnormal Neck

A

Limited range of motion, nuchal ridgity/meningismus, vertibral point vs. paraspinal tenderness, anterior and/or posterior cervical lymphadenopathy, JVD, carotid bruit

37
Q

Cardiovascular

A

Regular rate, regular rhythm, heart sounds normal

38
Q

Abnormal Cardiovascular

A

Tachycardia/Bradycardia, Irregularly irregular rhythm, murmurs/rubs/gallops/extrasytoles

39
Q

Pulses

A

2+ (easily palpable/normal), capillary refill less than 2 seconds

40
Q

Abnormal Pulses

A

0/1+/3+/4+, delayed capillary refill

41
Q

Respiratory

A

No respiratory distress, clear to auscultation bilaterally

42
Q

Abnormal Respiratory

A

Mild/Moderate/Severe Respiratory Distress, Tachypnea, accessory muscle use, pursed lip breathing, diminished breath sounds, wheezes, rales, rhonchi

43
Q

Gastrointestinal

A

Soft, nontender, negative Murphy’s sign, negative McBurney’s point tenderness, normal bowel sounds, no organomeagly

44
Q

Abnormal Gastrointestinal

A

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
Q

Genitourinary

A
46
Q

Musculoskeletal

A

Nontender T-Spine and L-Spine, no CVA tenderness, no tenderness to the extremities, no edema, normal ROM, Distal CMST

47
Q

Abnormal Musculoskeletal

A

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
Q

Skin

A

Warm, dry, normal color, no rashes, no induration, no fluctuance, no purulent drainage

49
Q

Abnormal Skin

A

Cool/hot to touch, diaphoretic, jaundice/cyanotic/pallor, Urticaria/wheals/maculopapular rash, Petechiae, induration, fluctuance, purulent drainage

50
Q

Lymphatic

A
51
Q

Neurological

A

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
Q

Psychological

A
53
Q

Average BP

A

120/80

54
Q

Average Pulse Rate

A

60-100 bpm

55
Q

Average Respiratory Rate

A

12-18

56
Q

Temperature

A

98.6 F

57
Q

SpO2

A

> 96%

58
Q

Hypotensive

A

Low BP

59
Q

Hypertensive

A

High BP

60
Q

Bradycardic

A

Low pulse rate

61
Q

Tachycardic

A

High pulse rate

62
Q

Bradypneic

A

Low respiratory rate

63
Q

Tachypneic

A

High respiratory rate

64
Q

Hypothermic

A

Low temperature

65
Q

Febrile

A

High temperature

66
Q

Hypoxic

A

Low SpO2

67
Q
A

Scribe Training (5 decks)

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