General PE

Question 1

1st two steps of PE

Answer 1

Wash hands, ask for vitals

Question 2

General + psych

Answer 2

Pt is a well appearing female, alert and grossly oriented with no signs of distress, her grooming and hygiene are appropriate for today’s visit and her mood and affect are pleasant

Question 3

EENT

Answer 3

1) Shine light in pt’s eyes:
Pupils are PERRL
2) Shine light in mouth
Oral mucosa is pink and moist
3) Look in ears
Tympanic membranes are pearly gray with the cone of light anterior, EAC is free of edema or excess cerumen
4) Look in nose
Internal mucosa is without rhinorrhea or cracking, septum is without deviation or perforation
5) Lymph node palpation: pre-auricular, post-auricular, suboccipital, submental, submandibular, anterior cervical, posterior cervical, supraclavicular, infraclavicular
No tenderness to palpation
6) Palpate thyroid
Thyroid is symmetric and of appropriate size

Question 4

Cardiac

Answer 4

Listen to all 4 heart valves
Appropriate rate and rhythm with no murmurs, rubs, or gallops

Question 5

Pulmonary

Answer 5

Auscultate 4 places on back, 1 on RML in front. Verbalize lobes.
Breath sounds are clear with no rhonchi, rales, or wheezing

Question 6

Abdomen

Answer 6

1) Look
Abdomen is flat and without surgical scars
2) Auscultate all 4 quadrants
Bowel sounds are appropriate in all 4 quadrants
3) Light palpation
4) Deep palpation
Abd is without tenderness to palpation

Question 7

Vascular

Answer 7

1) One UE and one LE pulse (radial and anterior tibial)
2+ bilaterally
2) LE edema (0-4 scale)
3) Skin is warm and dry

Question 8

MSK

Answer 8

1) Have pt curl arms and push arms against resistance
Upper extremity strength is 5 bilaterally
2)
Lower extremity strength is 5 bilaterally

Question 9

Neuro

Answer 9

1) UE/LE sensation
2) One UE and one LE reflex tested bilaterally (using 0-4+ scale)