Final SP Flashcards
SH, what’s a must to do, and what else is needed?
tobacco, alcohol, drugs
anything pertinent
What is the HPI?
what do you need to make sure to ask within this section?
OLDCAAARTS
have they had this before?
what do you think is happening?
What tests do you do for hip pain?
C-sign –> labral sign
Jump sign –> trochanteric bursitis
Rectus Femoris test –> rectus femoris contraction
Straight leg test*** –> IT band contracture, lumbosacral radiculopathy, mechanical low back pain
Thomas –> hip flexor contrition
When would you do a neuro exam?
What do you do for neuro exam? when would you do this?
headache, dizziness, lethargy
AAOx4 Stuff
CN2-12
sensations upper and lower, DTRs (if noting weakness, numbness, tingling)
cerebellar exam (if noting ataxia)
plantar response.
What do you put in the soap note for normal heart?
RRR, no murmurs, Strong S1 and S2, no edema.
What do you always need to do on the PE?
OSE
When would you do a neuro exam?
What do you do for neuro exam? when would you do this?
headache, dizziness, lethargy
CN2-12
PSH
past surgeries
what are the heart requirements?
listening posts for 2-3 beats per listening post
APTM
(not required, but can do peripheral
FH, what do you need to do
first degree relative… kids, parents, SIBLINGS
Meds, what do you need
Rx, OTC, supplements, dose frequency, what you take that for
What do you put on the soap note for general?
AAOx4, fatigued, NAD,
What tests do you do for an ankle/foot?
Squeeze/cross leg test for syndesmosis injury
Talar tilt test (inverting the talus) –> ATFL if increased ROM.
Alls?
Rx, env, food and what happens
What do you do for a cardiovascular exam besides listening?
Cap refill
pitting edema (0/4 is normal)
Allen test (artery refill)
pulse
What do you do for an URI?
Sinus check Lymph nodes Ear Mouth Lung exam
What do you put in the soap note for medications?
Med (dose on bottle) TID PRN
BID,TID,QID
ROS:
what are some good ones to ask?
general
neuro
General:
What tests do you do for low back pain?
Straight leg test
Thomas test –> iliopsoas tension, shortening, contracture
Gaenslen test –> sacroiliac joint dysfunction
What do you do for diabetic evaluation?
identify lesions on the foot, vibration sensing, DTRs, sensations, ulcers
What are the lung requirements?
explain the whole process
verbalize Inspection
Palpation bilaterally, concentrating on areas of pain, check for specialty tests
Percussion –> assess for tympani
Auscultation –> breathe through an open mouth, 2 on the front, 4 on the back.
PMH, what’s part of it?
Hospitalizations, ER visits, things a doctor treated in the past
What specialty tests do you do for a shoulder problem?
dislocation? bicipital problem? rotator cuff? AC?
Apprehension test –> repeat dislocation
Yergasons and speeds –> bicipital tendonitis
empty can, drop arm, near impingement, Hawkins, painful arc
Cross arm test
What do you do for neck pain?
what 4 things do you do for generalized neck pain and numbness?
what 3 things do you do for subarachnoid irritation?
Inspection, OSE, palpation of the thyroid and trachea
Spurling’s test
Compression test
Neck distraction
Roos test for thoracic outlet
nuchal rigidity –> flex head up and it hurts
Brudzinski’s
Kernigs
What tests do you do for abdominal pain?
what else do you note for during palpation?
Mcburneys, Rovsings –> Appendicitis
Murphys –> Gallbladder
Lloyd’s punch –> kidney problems
rigidity, guarding, rebound tenderness
What do you do for Low back pain? (not specialty test)
Inspection
OSE
Palpation
ROM
LE pulses bilat, sensations, DTRs, MS
What do you put on for lungs for the soap note?
Inspection - no erethema, no lesions, no yellowing of skin, no clubbing, non labored breathing
palpation - no tenderness to palpation, no nodules
Auscultation - lungs CTAB, negative tests
percussion - tactile femitus, lungs tympanic
Vomit/Diarrhea
Abdominal exam (mouth if sore throat too)
What tests do you do for knee pain?
Valgus for MCL
Varus for LCL
Anterior Drawer for ACL
Posterior drawer for PCL
Apley grind or distraction for meniscal injury
What do you put on the soap note for allergies?
NKDA, no environmental; +food (problem)
what do you do on a soap note for a neuro exam
AAOx4 stuff, CNII-CNXII intact, negative cerebellar ataxia, DTR +2/4 bilaterally, MS +5/5 bilaterally, sensations normal
What do you do for an HEENT for each one?
Head - normocephalic, atraumatic
Eyes - PERRLA, EOM intact
Ears - TMs visible, no effusion or perforation, normal external canal, no occlusion or lesion
Nose - nasal cavity patent and normal appearing mucosa
Mouth - no postnasal drip, normal dentition, buccal and palate mucosa, tongue mobile.
How do you perform the abdominal exam for complete points?
Drape the patient
fully expose the abdomen from the xiphoid to ASIS
Inspect, auscultate in all 4, auscultate renal arteries/aorta if pertinent, percuss in all 4, palpate light to deep
specialty test as indicated by the case
percuss for liver and spleen if pertinent
How do you write the FH for parents and what they have?
Parents: Mom (deceased-car accident) type 2 dm; Dad (deceased-cancer) HTN. siblings: older brother-HTN
What do you do for a cough?
1) what physical exams are you going to do?
2) what specific tests are you going to do within these?
Lung exam, HEENT depending on if it’s pneumonia.
Tactile fremitus for COPD, fibrosis, or increased with pneumonia
Hyperresonance of breath sounds for COPD/emphysema, asthma
Bronchopany, egophany, whispered pectoriloquy
