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Medical Scribe > Objective: General/Constitutional, Head, Eyes, Ears, Mouth/Throat, Neck/Cervical Spine > Flashcards

Objective: General/Constitutional, Head, Eyes, Ears, Mouth/Throat, Neck/Cervical Spine Flashcards

1
Q

Normal General/Constitutional

A

no acute distress (NAD)
well developed, well nourished
alert

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2
Q

no acute distress

A

NAD

normal general/constitutional

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3
Q

Abnormal General/Constitutional

A

distress + severity (due to pain)
cachectic/emaciated/malnourished
somnolent, obtunded, unresponsive
c-collar, backboard, oxygenation

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4
Q

cachectic

A

severely underweight

abnormal general/constitutional

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5
Q

emaciated/malnourished

A

underweight

abnormal general/constitutional

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6
Q

somnolent

A

sleepy

abnormal general/constitutional

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7
Q

obtunded

A

stupor, not with it

abnormal general/constitutional

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8
Q

c-collar, backboard, oygenation

A

mostly used in emergency med

abnormal general/constitutional

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9
Q

cephallic-

A

head

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10
Q

normal head

A

atraumatic/normocephallic (AT/NC)

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11
Q

atraumatic/normocephallic

A

AT/NC

normal head

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12
Q

abnormal head

A

signs of trauma
sinus tenderness
angioedema

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13
Q

angioedema

A

painless swelling
tends to happen on face or lips
can indicate allergic rxn
abnormal head

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14
Q

normal eyes

A

pupil equal, round, reactive to light (PERRL)
extraocular movements intact (EOMI)
sclerae are anicteric
normal conjunctiva

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15
Q

abnormal eyes

A 
anisocoria
EOM entrapment
scleral icterus
pale conjunctiva
conjunctival injection
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16
Q

icteric

A

yellow, yellowing; usually caused by liver failure/injury

abnormal eyes

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17
Q

conjunctiva

A

tissue under the eyes

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18
Q

pupils equal, round, reactive to light

A

PERRL, normal eyes

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19
Q

extraocular movement intact

A

EMOI, normal eyes

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20
Q

anisocoria

A

unequal pupils
could indicate stroke
abnormal eyes

21
Q

extraocular muscle

A

EOM

movement of the eyes

22
Q

EOM entrapment

A

one eye can’t move, abnormal eye

23
Q

pale conjunctiva

A

abnormal eye

could indicate anemia

24
Q

conjunctival injection

A

abnormal eye

could indicate conjunctivitis

25
Q

normal ears

A

tympanic membranes normal

26
Q

tympanic membranes

A

TM, ear drums

27
Q

abnormal ears

A

TM erythema, bulging, dullness

TM obscured by cerumen

28
Q

cerumen

A

earwax

29
Q

erythema

A

redness

30
Q

normal mouth/throat

A

moist mucous membranes
oropharynx (OP) normal
normal dentition

31
Q

abnormal mouth/throat

A

dry mucous membranes (DMM)
pharyngeal erythema, tonsillar exudate, tonsillar hypertrophy
edentulous, dental caries

32
Q

dry mucous mebranes

A

DMM
indicates dehydration
abnormal mouth/throat

33
Q

oropharynx

A

OP

34
Q

dentition

A

teeth

35
Q

exudate

A

discharge, pus

36
Q

hypertrophy

A

enlargement

37
Q

edentulous

A

missing teeth

abnormal mouth

38
Q

dental caries

A

severe cavities

abnormal mouth

39
Q

symptoms of bacterial infection in the mouth

A

swollen uvula, whitish stops, red swollen tonsils, throat redness, gray furry tongue

40
Q

symptoms of viral infection in the mouth

A

red swollen, throat redness

41
Q

normal neck/cervical spine

A

supple

42
Q

abnormal neck/cervical spine

A 
thyromegaly
jugular venous distension (JVD)
carotid bruit
cervical lymphadenopathy
limited ROM
vertebral point vs paraspinal tenderness
43
Q

-mega/-megaly

A

enlargement

44
Q

jugular venous distension

A

JVD
prominent jugular vein in the neck
associated with excess of fluid, back up of pressure, issue from the heart
abnormal neck

45
Q

carotid bruit

A

heard through auscultation
whistling sounds
narrowing of the artery
abnormal neck

46
Q

range of motion

A

ROM

47
Q

vertebral point tenderness

A

pain on the spine bone

abnormal cervical spine

48
Q

paraspinal tenderness

A

pain on the soft tissue around the spine

abnormal cervical spine

Medical Scribe (6 decks)

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