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Clinical Assessment > PE note per section > Flashcards

PE note per section Flashcards

1
Q

General Survey

A 
body habitus
nutritional state
sexual development
presenting appearance
hygiene (odors body and breath)
stated vs apparent age
demeanor
facial affect or expression
posture
gait
level of conciousness
apparent pain 
signs of distress
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2
Q

Mental status

A 
Speech
language
mood
thought content
perceptions
insight
judgement
orientation
attention
memory
information and vocabulary
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3
Q

Pulse

A

unusually fast or slow

rhythm regular or irregular

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4
Q

respirations

A

observing rate
rhythm
depth
effort of breathing

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5
Q

skin

A 
color
temperature
texture
turgor
mobility
moisture
rashes
lesions
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6
Q

hands and nails

A 
cyanosis
clubbing
nail deformities
tremors
erythema or pallor (palmar creases of the hands)
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7
Q

skull

A

general size

contour

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8
Q

scalp

A

scaliness
nei
lesions

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9
Q

hair

A

quantity
distribution
pattern of loss
dandruff

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10
Q

face, nose, mouth

A 
symmetry
contours
involuntary movements
edema
lesions
masses and expression
pathognomonic facies?
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11
Q

TMJ

A

swelling

redness

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12
Q

palpate hair and scalp

A 
hair texture
quantity and distribution
scalp and skull for deformities
tenderness
lesions
scaliness
lumps
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13
Q

TMJ

A

ROM
pain
crepitus
clicking

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14
Q

neck

A

symmetry
masses
scars
tracheal position

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15
Q

thyroid

A

movement of masses
masses
thyroid enlargement

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16
Q

trachea

A

deviation from midline

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17
Q

Cervical lymph nodes: locations

A 
occipital
posterior auricular
preauricular
posterior cervical
superficial cervical
suprclavicular 
deep cervical
tonsillar
submandibular
submental
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18
Q

Cervical lymph nodes…note:

A 
size
shape
mobility
consistency
lymphatic enlargement
tenderness 
induration
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19
Q

thyroid

A 
size
shape
consistency
tenderness
masses or nodules
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20
Q

eyebrows

A

quanitity
distribution
scaliness

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21
Q

eyelids

A 
edema
color
lesions
direction of eyelashes 
adequacy with which they close
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22
Q

lacrimal gland and sac

A

swelling

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23
Q

conjunctiva and sclera

A

color
vascular pattern
nodules
swelling

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24
Q

iris and pupils

A

size
shape
symmetry

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25
Q

note depression of lower lids: sclera and palpebral conjunctive

A 
icterus
conjunctival inflammation
pterygiums
pingueculae
xantelasmas
ireis lesions
pupillary inequality
nystagmus
strabismus
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26
Q

pupillary reflexes

A

direct and consensual light reflexes

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27
Q

accommodative reflex

A

convergence of the eyes

pupillary constriction

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28
Q

Extraocular Muscles

A

EOM paralysis
disconjugate gaze
nystagmus
lid lag

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29
Q

visual fields

A

gross visual field defects

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30
Q

fundoscopy of eyes: inpect

A 
red reflex
disc
retina-arterioles
veins
fovea
macula
vitreous 
lens
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31
Q

Fundoscopy of eyes: Note

A 
opacities in the ocular media
disc cupping
vessel narrowing
a-V nicking
pilledema
retinal exudates 
retinal hemorrhages
macular changes
disc sharpness and color
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32
Q

nose inspection

A 
septal deviation
septal perforations
mucosal inflammation
nasal discharge
lesions
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33
Q

nose palpation

A

tenderness
patency of each nostril
frontal sinus tenderness
maxillary sinus tenderness

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34
Q

Mouth inspection

A 
lips
buccal mucosa
gums
teeth
tongue
palate
floor of the mouth
posterior pharynx
tonsillar pillars and tonsils
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35
Q

Mouth inspection (overall note)

A 
REMOVE DENTURES:
color
inflammation
exudate
swelling
moisture
lesions
ulcers
dental arries
tonsilar enlargement
breath odor
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36
Q

lips

A 
moisture
color
lumps
ulcers
cracking
scaliness
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37
Q

buccal mucosa

A

color
ulcers
white patches
nodules

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38
Q

gums

A

swelling

ulceration

39
Q

teeth

A

carries and looseness

40
Q

tongue

A

erythema
nodules
ulcerations

41
Q

palate, floor of mouth, posterior pharynx, tonsillar pillars and tonsils

A

exudate
swelling
ulceration
tonsilar enlargement

42
Q

ears: auricles

A 
deformities
keloids
lesions
lumps
discarge from EAC
43
Q

ear: palpate note

A

tenderness or masses

44
Q

ears otoscopic exam: inspect

A

tympanic membrane and EAC

45
Q

ears otoscopic exam: note

A 
discharge
foreign bodies
erythema
edema
color and contour of eardrum
tympanic scarring or perforation
TM bulging or retraction
air-fluid levels
masses
bleeding
vascular lesions
46
Q

axillary and epitrochlear nodes

A

lymphatic size
consistency
enlargement or tenderness

47
Q

Chest inspection

A 
chest symmetry
expansion or deformities
respiratory pattern and distress
intercostal or supraclavicular retractions
abdominal vs thoracic breathing
48
Q

thoracic expansion

A

asymmetric chest expansion or splinting of respirations

49
Q

tactile fremitus

A

increased or decreased fremitus

50
Q

Percuss chess

A

unexpected dullness or hyperresonance

51
Q

Auscultate chest

A 
pitch
intensity
loudness
quality of breath sounds
Note:
increased, decreased or abnormal breath sounds
crackles
wheezes
rhonci
rubs
52
Q

cardiovacular perecordium inspection

A

apical impulse or PMI if visible

any abnormal precordial motion including lifts or heaves

53
Q

carotid pulse

A

amplitude
timing
contour of pulse wave or thrills

54
Q

apical impulse

A 
abnormal motion including lifts, heaves or thrills
abnormal pulsations
location
size
force of the apical impulse
55
Q

caroids

A

carotid bruits

56
Q

Note precordium:auscultate

A

regular or irregular rhythm

57
Q

Note on 1st and 2nd heat sounds

A

loudness
splitting
splitting? affected by respiration or position
S3 or S4 present?

58
Q

Murmur

A 
timing (systolic vs diastolic)
location (best heard)
Grade (1-6)
Radiation
Pitch
Quality
59
Q

S3 and S4 notes

A

low pitched diastolic rumble of mitral or tricuspid stenosis or an S3 and/or S4

60
Q

murmur of aortic regurgitation

A

high pitched early diastolic murmur of aortic insufficiency

61
Q

Peripheral pulses

A

rate
rhythm
quality

62
Q

PV lower extremities

A 
skin temperature
edema
decreased hair growth
lesions
ulcerations
varicocities
63
Q

inspection of abdomen

A 
contour (flat, scaphoid, rounded, protruberant)
symmetry
angiomata
ecchymoses
striae
rashes
lesions
scars
visible peristalsis
arterial pulsations
distended abdominal wall veins
64
Q

Auscultation of abdomen

A

bowel sounds (increased, decreased, or normal)

65
Q

auscultation abdomen: vascuar

A

any bruits

66
Q

Percussion of abdomen

A

unusual tympani or dullness

67
Q

splenic percussion

A

change in percussion note from resonant/tympanic to dullness on inspiration=spenic enlargement

68
Q

Palpation of abdomen

A

tenderness
organomegally
masses

69
Q

Ingunal nodes

A

enlargement
induration
tenderness

70
Q

CVA tenderness

A

significant tenderness

71
Q

musculoskeletal

A 
edema
deformity
color
hypertrophy
abdnormal joint positioning
atrophy
alignment
unusual body contours or prominence
72
Q

suculoskeletal palpation

A 
edema
deformity
temperature
hypertrophy
atrophy
crepitus
clicking
locking
instability
laxity
unusual bony contours or prominences
joint positioning
73
Q

musculoskeletal ROM

A

decreased ROM or pain

74
Q

Neurological: mental status exam

A 
overall presentation and appearance
level of consciousness
behavior
mood
affect
language
orientation
attention
memory
abstract thinking
75
Q

CN1

A

anosmia

76
Q

CN V

A

assemmetry of masseter muscle contraction

77
Q

CN VII

A

asymetry of facial movement

78
Q

CN IX and X

A

if soft palate fails to rise on one side

hoarseness or dysphonia?

79
Q

CN XI

A

strength and contraction of muscle

80
Q

CN XII

A

deviation
asymmetry
fasciculation
atrophy

81
Q

Motor inspection

A

muscle atrophy or bulk
tremors
tics
fasciculations

82
Q

Motor muscle tone

A

spasticity
rigidity
decreased muscle tone

83
Q

Motor muscle strenth

A

Weakness in:

84
Q

alternative screening tests: Motor muscle strength

A

UE:
handgrip strength

LE:
Observing patient rising from chair
walking on toes
walking on heals

85
Q

Cerebellar function: coordination

A

tremors or cerebellar disease

86
Q

Cerebellar function: Gait

A

ataxia
limp
weakness
orther abnormal gait

87
Q

heal-toe walk

A

ataxia

88
Q

cerebellar function: stance

A

romberg test

difficulty maintaining balance with eyes open or closed

89
Q

Cerebellar function: pronator drift

A

pronation of one forearm
downward drift of arm with flexion of fingers and elbow

tap of arm after 20 seconds: smooth return of arms to horizontal position

90
Q

Sensory: Crude touch

A

sensory deficits

91
Q

tactile discrimination

A

Stereognosis

Graphesthesia

92
Q

reflexes

A

increased, decreased, absent reflexes

93
Q

Ankle clonus

A

sustain clonus

Clinical Assessment (3 decks)

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