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Scribe America > OP Course 2: PE - Objective > Flashcards

OP Course 2: PE - Objective Flashcards

1
Q

“Objective” refers to?

A

Factual information; comes from provider

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2
Q

“Auscultation” refers to?

A

Listening w/ stethoscope

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3
Q

“Palpation” refers to?

A

Pressing on an area

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4
Q

“Chachetic” refers to?

A

emaciated; malnourished

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5
Q

“Diffuse” refers to?

A

Widespread

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6
Q

What are some normal terms you may see in the “general/constitutional” section of the physical exam?

A

No acute distress (NAD)

Well developed/nourished

Alert

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7
Q

What are some abnormal terms you may see in the “general/constitutional” section of the physical exam?

A

Mild/moderate/severe distress

Cachectic/Emaciated/Malnourished

Somnolent, obtunded, unresponsive, C-collar, backboard, oxygenation 91% 10L O2 NC

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8
Q

What is the normal term you may see in the “head” section of the physical exam?

A

Atraumatic/Normocephalic (AT/NC)

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9
Q

What are some abnormal terms you may see in the “head” section of the physical exam?

A

Any signs of trauma

Sinus tenderness

Angioedema

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10
Q

What does PERRL stand for?

A

Pupils equal, round, reactive to light

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11
Q

What does EOMI stand for?

A

Extraocular movements intact

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12
Q

What are some normal terms you may see in the “eyes” section of the physical exam?

A

PERRL or PERRLA

EOMI

Sclerae are anicteric

Normal conjunctiva

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13
Q

What are some abnormal terms you may see in the “eyes” section of the physical exam?

A

Anisocoria (unequal pupils)

EOM entrapment

Scleral icterus (yellowing)

Pale conjunctiva (anemia) or conjunctival injection (conjunctivitis)

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14
Q

What is a normal term you may see in the “ears” section of the physical exam?

A

Tympanic membranes normal (TMs normal)

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15
Q

What are some abnormal terms you may see in the “ears” section of the physical exam?

A

TM erythema

TM bulging

TM dullness

TM obscured by cerumen (earwax)

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16
Q

What are some normal terms you may see in the “mouth/throat” section of the physical exam?

A

Moist mucous membranes

Oropharynx (OP) normal

Normal dentition

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17
Q

What are some abnormal terms you may see in the “mouth/throat” section of the physical exam?

A

Dry mucous membranes (DMM)

Pharyngeal erythema

Tonsillar exudate

Tonsillar hypertrophy

Edentulous

Dental caries

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18
Q

What is a normal term you may see in the “neck & cervical spine” section of the physical exam?

A

Supple

No carotid bruit

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19
Q

What are some abnormal terms you may see in the “neck & cervical spine” section of the physical exam?

A

Thyromegaly

Jugular venous distension (JVD)

Carotid bruit

Cervical lymphadenopathy

Limited ROM

Vertebral point vs. paraspinal tenderness

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20
Q

What are some normal terms you may see in the “cardiovascular” section of the physical exam?

A

Regular rate

Regular rhythm

Heart sounds normal

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21
Q

What are some abnormal terms you may see in the “cardiovascular” section of the physical exam?

A

Tachycardia/Bradycardia

Irregularly irregular rhythm (Afib)

Murmur, gallops or rubs

Extrasystoles

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22
Q

What are the following values on the pulse grading scale? Which value is the normal value?

0 = ?

1+ = ?

2+ = ?

3+ = ?

4+ = ?

A

0 = absent

1+ = barely palpable

2+ = easily palpable

3+ = full

4+ = bounding/aneurysmal

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23
Q

What are some normal terms you may see in the “perfusion” section of the physical exam?

A

Pulses equal & symmetric

Capillary refill < 2 sec

24
Q

What are some abnormal terms you may see in the “perfusion” section of the physical exam?

A

Unequal pulses

Delayed capillary refill

25
Q

What are “vesicular” breath sounds?

A

Normal breath sounds

26
Q

What are some normal terms you may see in the “pulmonary” section of the physical exam?

A

No respiratory distress

Normal respiratory rate

Normal effort

Breath sounds clear and equal

Clear to auscultation bilaterally

27
Q

What are some abnormal terms you may see in the “pulmonary” section of the physical exam?

A

Mild –> severe respiratory distress

Tachypnea

Accessory muscle use

Diminished (quiet) breathing

Wheezes, rales, rhonchi

28
Q

Label the following aspects of the abdomen:

Epigastrium, R & L Flanks, Generalized, Suprapubic, Periumbilical, LLQ, RUQ, RLQ, LUQ

A
29
Q

What are the three “peritoneal signs”?

A

Rebound tenderness

Rigidity

Voluntary guarding

30
Q

What are some normal terms you may see in the “abdominal” section of the physical exam?

A

Soft

Non-tender

No peritoneal signs

Normal bowel sounds

Nondistended

31
Q

What are some abnormal terms you may see in the “abdominal” section of the physical exam?

A

Rigid (involuntary guarding)

Mild –> severe tenderness

Peritoneal signs (Rebound tenderness, rigidity, voluntary guarding)

Absent/hypoactive/hyperactive bowel sounds

Organomegaly

Distended

32
Q

What does a positive murphy’s sign refer to?

A

gallbladder

33
Q

What does “Positive McBurney’s point” refer to?

A

Appendix

34
Q

What does a positive Psoas sign refer to?

A

Appendix

35
Q

What does a positive obturator sign refer to?

A

Appendix

36
Q

What does a positive Rovsing’s sign refer to?

A

Appendix

37
Q

What are some normal terms you may see in the “musculoskeletal/extremities” section of the physical exam?

A

Non-tender

Full ROM

Distal circulation, sensory, motor, tendon (CSMT) intact

38
Q

What are some abnormal terms you may see in the “musculoskeletal/extremities” section of the physical exam?

A

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)

39
Q

What are some normal terms you may see in the “back” section of the physical exam?

A

Non-tender thoracic and lumbar spine

40
Q

What are some abnormal terms you may see in the “back” section of the physical exam?

A

Paraspinal tenderness (muscular)

Vertebral point tenderness (spinal injury)

Costovertebral angle (CVA) tenderness

41
Q

What are some normal terms you may see in the “integumentary” section of the physical exam?

A

Warm

Dry

Normal color

No rash

Atraumatic

No erythema, warmth, or drainage

42
Q

What are some abnormal terms you may see in the “integumentary” section of the physical exam?

A

Cool or hot to touch

diaphoretic

Jaundice, cynotic, pallor

Any signs of rash

Any signs of trauma

Any signs of infection

43
Q

What are some normal terms you may see in the basic neurological exam?

A

Alert

Oriented x4

Normal speech

Nonfocal neuro exam

44
Q

What are some abnormal terms you may see in the basic neurological exam?

A

Somnolent, obtunded, unresponsive

Disoriented to person, place, time, or situation (x4)

Aphasia (expressive or receptive) dysarthria

Any abnormal findings

45
Q

What are some normal terms you may see in the motor & sensation part of the neurological section of the physical exam?

A

Motor strength 5/5 and symmetric

Sensation intact

46
Q

What are some abnormal terms you may see in the motor & sensation part of the neurological section of the physical exam?

A

Extremity weakness (_/5)

Pronator drift

Hypoesthesia (decreased sensation)

Numbness

47
Q

What do the following strength values correspond to?

5/5 = ?

4/5 = ?

3/5 = ?

2/5 = ?

1/5 = ?

0/5 = ?

A

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

48
Q

What is a normal Babinski reflex (in an adult)?

A

Downgoing toes

49
Q

What is an abnormal Babinski reflex?

A

Upgoing toes

50
Q

What do the following values for Deep Tendon Reflexes (DTRs) represent?

0 = ?

1+ = ?

2+ = ?

3+ = ?

4+ =?

A

0 = absent

1+ = hypoactive

2+ = normal

3+ = increased

4+ = unsustained clonus

51
Q

What are some normal terms you may see on the “psychiatric” section of the physical exam?

A

Normal affect

Normal judgment

Normal insight

Normal speech

52
Q

What are some abnormal affects that you may see in the “psychiatric” section of the physical exam?

A

flat affect

odd affect

tearful

depressed

hypomanic

poor eye contact

53
Q

What are some abnormal “judgments” that you may see in the “psychiatric” section of the physical exam?

A

Suicidal or homicidal

Hallucinations

Flight of ideas (loose association)

Paranoid

54
Q

What are some abnormal “insights” that you may see in the “psychiatric” section of the physical exam?

A

Denies illness/symptoms

Noncompliant with treatment

55
Q

What are some abnormal “speech patterns” that you may see in the “psychiatric” section of the physical exam?

A

Tangential speech

Pressured speech

56
Q

What constitutes a complete physical exam?

A

9 body systems (and 18 total findings)

Scribe America (4 decks)

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