OP Course 2: PE - Objective Flashcards
“Objective” refers to?
Factual information; comes from provider
“Auscultation” refers to?
Listening w/ stethoscope
“Palpation” refers to?
Pressing on an area
“Chachetic” refers to?
emaciated; malnourished
“Diffuse” refers to?
Widespread
What are some normal terms you may see in the “general/constitutional” section of the physical exam?
No acute distress (NAD)
Well developed/nourished
Alert
What are some abnormal terms you may see in the “general/constitutional” section of the physical exam?
Mild/moderate/severe distress
Cachectic/Emaciated/Malnourished
Somnolent, obtunded, unresponsive, C-collar, backboard, oxygenation 91% 10L O2 NC
What is the normal term you may see in the “head” section of the physical exam?
Atraumatic/Normocephalic (AT/NC)
What are some abnormal terms you may see in the “head” section of the physical exam?
Any signs of trauma
Sinus tenderness
Angioedema
What does PERRL stand for?
Pupils equal, round, reactive to light
What does EOMI stand for?
Extraocular movements intact
What are some normal terms you may see in the “eyes” section of the physical exam?
PERRL or PERRLA
EOMI
Sclerae are anicteric
Normal conjunctiva
What are some abnormal terms you may see in the “eyes” section of the physical exam?
Anisocoria (unequal pupils)
EOM entrapment
Scleral icterus (yellowing)
Pale conjunctiva (anemia) or conjunctival injection (conjunctivitis)
What is a normal term you may see in the “ears” section of the physical exam?
Tympanic membranes normal (TMs normal)
What are some abnormal terms you may see in the “ears” section of the physical exam?
TM erythema
TM bulging
TM dullness
TM obscured by cerumen (earwax)
What are some normal terms you may see in the “mouth/throat” section of the physical exam?
Moist mucous membranes
Oropharynx (OP) normal
Normal dentition
What are some abnormal terms you may see in the “mouth/throat” section of the physical exam?
Dry mucous membranes (DMM)
Pharyngeal erythema
Tonsillar exudate
Tonsillar hypertrophy
Edentulous
Dental caries
What is a normal term you may see in the “neck & cervical spine” section of the physical exam?
Supple
No carotid bruit
What are some abnormal terms you may see in the “neck & cervical spine” section of the physical exam?
Thyromegaly
Jugular venous distension (JVD)
Carotid bruit
Cervical lymphadenopathy
Limited ROM
Vertebral point vs. paraspinal tenderness
What are some normal terms you may see in the “cardiovascular” section of the physical exam?
Regular rate
Regular rhythm
Heart sounds normal
What are some abnormal terms you may see in the “cardiovascular” section of the physical exam?
Tachycardia/Bradycardia
Irregularly irregular rhythm (Afib)
Murmur, gallops or rubs
Extrasystoles
What are the following values on the pulse grading scale? Which value is the normal value?
0 = ?
1+ = ?
2+ = ?
3+ = ?
4+ = ?
0 = absent
1+ = barely palpable
2+ = easily palpable
3+ = full
4+ = bounding/aneurysmal
What are some normal terms you may see in the “perfusion” section of the physical exam?
Pulses equal & symmetric
Capillary refill < 2 sec
What are some abnormal terms you may see in the “perfusion” section of the physical exam?
Unequal pulses
Delayed capillary refill
What are “vesicular” breath sounds?
Normal breath sounds
What are some normal terms you may see in the “pulmonary” section of the physical exam?
No respiratory distress
Normal respiratory rate
Normal effort
Breath sounds clear and equal
Clear to auscultation bilaterally
What are some abnormal terms you may see in the “pulmonary” section of the physical exam?
Mild –> severe respiratory distress
Tachypnea
Accessory muscle use
Diminished (quiet) breathing
Wheezes, rales, rhonchi
Label the following aspects of the abdomen:
Epigastrium, R & L Flanks, Generalized, Suprapubic, Periumbilical, LLQ, RUQ, RLQ, LUQ
What are the three “peritoneal signs”?
Rebound tenderness
Rigidity
Voluntary guarding
What are some normal terms you may see in the “abdominal” section of the physical exam?
Soft
Non-tender
No peritoneal signs
Normal bowel sounds
Nondistended
What are some abnormal terms you may see in the “abdominal” section of the physical exam?
Rigid (involuntary guarding)
Mild –> severe tenderness
Peritoneal signs (Rebound tenderness, rigidity, voluntary guarding)
Absent/hypoactive/hyperactive bowel sounds
Organomegaly
Distended
What does a positive murphy’s sign refer to?
gallbladder
What does “Positive McBurney’s point” refer to?
Appendix
What does a positive Psoas sign refer to?
Appendix
What does a positive obturator sign refer to?
Appendix
What does a positive Rovsing’s sign refer to?
Appendix
What are some normal terms you may see in the “musculoskeletal/extremities” section of the physical exam?
Non-tender
Full ROM
Distal circulation, sensory, motor, tendon (CSMT) intact
What are some abnormal terms you may see in the “musculoskeletal/extremities” section of the physical exam?
Bony tenderness (fracture)
Soft tissue tenderness (contusion)
Decreased ROM 2° pain
Pulse/sensory/motor deficits
Tendon laxity
Pitting edema (trace to 4+)
Calf tenderness, palpable cords/Homan’s sign (DVT)
What are some normal terms you may see in the “back” section of the physical exam?
Non-tender thoracic and lumbar spine
What are some abnormal terms you may see in the “back” section of the physical exam?
Paraspinal tenderness (muscular)
Vertebral point tenderness (spinal injury)
Costovertebral angle (CVA) tenderness
What are some normal terms you may see in the “integumentary” section of the physical exam?
Warm
Dry
Normal color
No rash
Atraumatic
No erythema, warmth, or drainage
What are some abnormal terms you may see in the “integumentary” section of the physical exam?
Cool or hot to touch
diaphoretic
Jaundice, cynotic, pallor
Any signs of rash
Any signs of trauma
Any signs of infection
What are some normal terms you may see in the basic neurological exam?
Alert
Oriented x4
Normal speech
Nonfocal neuro exam
What are some abnormal terms you may see in the basic neurological exam?
Somnolent, obtunded, unresponsive
Disoriented to person, place, time, or situation (x4)
Aphasia (expressive or receptive) dysarthria
Any abnormal findings
What are some normal terms you may see in the motor & sensation part of the neurological section of the physical exam?
Motor strength 5/5 and symmetric
Sensation intact
What are some abnormal terms you may see in the motor & sensation part of the neurological section of the physical exam?
Extremity weakness (_/5)
Pronator drift
Hypoesthesia (decreased sensation)
Numbness
What do the following strength values correspond to?
5/5 = ?
4/5 = ?
3/5 = ?
2/5 = ?
1/5 = ?
0/5 = ?
5/5 = normal strength
4/5 = very mildly weak
3/5 = unable to overcome resistance
2/5 = unable to overcome cravity
1/5 = slight contraction, no movement
0/5 = flaccid/limp
What is a normal Babinski reflex (in an adult)?
Downgoing toes
What is an abnormal Babinski reflex?
Upgoing toes
What do the following values for Deep Tendon Reflexes (DTRs) represent?
0 = ?
1+ = ?
2+ = ?
3+ = ?
4+ =?
0 = absent
1+ = hypoactive
2+ = normal
3+ = increased
4+ = unsustained clonus
What are some normal terms you may see on the “psychiatric” section of the physical exam?
Normal affect
Normal judgment
Normal insight
Normal speech
What are some abnormal affects that you may see in the “psychiatric” section of the physical exam?
flat affect
odd affect
tearful
depressed
hypomanic
poor eye contact
What are some abnormal “judgments” that you may see in the “psychiatric” section of the physical exam?
Suicidal or homicidal
Hallucinations
Flight of ideas (loose association)
Paranoid
What are some abnormal “insights” that you may see in the “psychiatric” section of the physical exam?
Denies illness/symptoms
Noncompliant with treatment
What are some abnormal “speech patterns” that you may see in the “psychiatric” section of the physical exam?
Tangential speech
Pressured speech
What constitutes a complete physical exam?
9 body systems (and 18 total findings)
