Physical Exam Flashcards
Benign
Not harmful
Anatomical Position
A frame of reference used to describe anatomy and movement.
Tenderness
Pain felt upon palpation.
Icterus
Yellowing, also known as jaundice.
Purulent
Pus-like
Erythema
Redness
Organomegaly
Organ enlargement
Perfusion
The flow of blood through the body’s blood vessels.
Affect
The patient’s immediate expression of emotion.
Consolable
Able to be comforted.
GCS
Glasgow Coma Exam – used to assess the level of consciousness in trauma pts.
General/Constitutional – Normal Physical Exam
- No Acute Distress (NAD) – comfortable appearing.
- Well-developed, Well-nourished.
- Alert
General/Constitutional – Abnormal Physical Exam
- Mild/Moderate/Severe Distress (due to pain).
- Cachectic/Emaciated/Malnourished
- Somnolent, Obtunded, Unresponsive.
- C-Collar, Backboard, Oxygenation (91% 10L O2 NC)
Somnolent and Obtunded = drowsy but responsive.
Head – Normal Physical Exam
Atraumatic/Normocephalic (AT/NC)
“a” – without
-cephalic – head
Peri- – around
Periorbital – around the eyes.
Head – Abnormal Physical Exam
- Any signs of trauma
- Sinus tenderness
- Angioedema
- Allergic reaction
Angioedema – swelling of the eyes, lips, throat, or tongue.
Eyes – Normal Physical Exam
- Pupils Equal, Round, Reactive to Light (PERRL)
- Extraocular Movements Intact (EOMI)
- Sclerae Anicteric
- Normal Conjunctiva
- Normal Cornea (External Eye – with Wood’s lamp or Fluorescein)
Sclera – the white part of the eyes.
Anicteric – without yellowing.
Eyes – Abnormal Physical Exam
- Anisocoria (unequal pupils)
- EOM entrapment
- Scleral Icterus (Liver Failure)
- Pale conjunctiva (Anemia)
- Conjunctival injection (Conjunctivitis)
- Fluorescein uptake (Corneal Abrasion or Ulcerations)
! Do NOT use erythema for the eyes, document conjunctival injection, not erythema (the eyes are the exception to erythema).
Ears/Throat – Normal Physical Exam
- Tympanic Membranes (TMs) Normal
- Moist Mucous Membranes
- Oropharynx (OP) Normal
- Normal dentition
Ears/Throat – Abnormal Physical Exam
- TM erythema, bulging, or dullness
*Sometimes the doctor cannot visualize the TM because it’s obstructed by cerumen (earwax)
- Dry mucous membranes (DMM)
- Pharyngeal erythema
- Tonsillar exudate
- Tonsillar hypertrophy (enlargement/overgrowth)
- Edentulous (toothlessness)
- Dental caries (cavities)
- Uvular Shift
- Tonsillar Asymmetry
Uvular Shift and Tonsillar Asymmetry are signs of Peritonsillar Abscess
Tonsillar exudate – fluid secreted by the tonsils in response to infection or inflammation.
! When the doctor checks the TM, look out for OM.
Neck and Cervical Spine – Normal Physical Exam
- Nontender Cervical Spine (C-Spine)
- Supple (free movement of a body part)
- Normal appearance and normal ROM (range of motion).
Neck and Cervical Spine – Abnormal Physical Exam
- Vertebral Point (Midline) vs. Paraspinal Tenderness
- Nuchal rigidity, Meningismus, Limited ROM
- Carotid bruit
- Cervical lymphadenopathy (swollen lymph nodes)
- Jugular Venous Distension (JVD)
- Thyromegaly
! Avoid a contradiction if the patient has a C-collar on – cannot document full ROM.
Vertebral Tenderness – Possible spinal fracture.
Cardiovascular (CV) – Normal Physical Exam
- Regular Rate
- Regular Rhythm
- Heart sounds normal
Rate – The number of times the ventricle contract per minute.
Rhythm – A measurement of whether the heart beats at regular intervals (lub-dub noise).
Cardiovascular (CV) – Abnormal Physical Exam
- Tachycardia(>100 bpm) / Bradycardia (<60 bpm)
- Irregularly Irregular Rhythm
- Murmur (e.g. 2/6 Systolic Ejection Murmur)
- Gallop or Rubs
- Extrasystoles (extra beats)
Murmur – Abnormal heart sounds due to malfunctioning heart valve, rated on a 1-6 scale.
Gallop – Three or four sounds, resembling a horse’s gallop.
Rub – A scratching, grating sound of the heart, concerning for pericarditis (the heart is rubbing the sac surrounding it).
Perfusion – Physical Exam
The flow of blood through the body’s blood vessels.
- Radial Pulse
- Carotid Pulse
- Femoral Pulse
- Dorsalis Pedis (DP) Pulse
- Posterior Tibial (PT) Pulse
Perfusion – Documentation
Pulses Equal and Symmetric, Capillary Refill less than 2 seconds
Delayed capillary refill
0 = Absent
1+ = Barely palpable
2+ = Easily palpable (Normal)
3+ = Full
4+ = Bounding/Aneurysmal
! You must document the strength and the location of the pulses on the physical exam.
Capillary refill – a measure of time it takes for the distal capillary bed to regain color after pressure has been applied to cause blanching. A normal capillary refill in less than 2 seconds.
Pulmonary – Normal Physical Exam
- No respiratory distress
- Normal respiratory rate
- Normal effort
- Breath Sounds Clear and Equal
Pulmonary – Abnormal Physical Exam
- Mild/Moderate/Severe respiratory distress
- Tachypnea (sign of respiratory distress)
- Accessory muscle use (sign of respiratory distress)
- Diminished (quiet) breath sounds
- Wheezes (inspiratory or expiratory)
- Rales (Crackles)
- Rhonchi
Pulmonary – Contradictions
Normal Finding
- No respiratory distress
- Normal effort
Contradictory Abnormal Finding
- Mild/Moderate/Severe Respiratory Distress
- Tachypnea
- Accessory muscle use
Normal Finding
- Clear to auscultation bilaterally (CTAB)
- Normal breath sounds
Contradictory Abnormal Finding
- Diminished breath sounds
- Inspiratory/expiratory
- Wheezes (Insp. Exp.) – High pitches noise (Asthma)
- Rales (Crackles) – Liquid/Fluid (CHF)
- Rhonchi – Junky noise (PNA and COPD)
Abdominal – Normal Physical Exam
- Soft
- Non-tender
- No peritoneal signs
Abdominal – Abnormal Physical Exam
- Rigid (involuntary guarding)
- Mild/Mod/Severe tenderness
- Rebound Tenderness
- Rigidity (Involuntary Guarding)
- Voluntary Guarding
Tenderness – pain increases with pressure during palpation.
Rebound – pain increases upon releasing pressure.
G.R.R – Guarding (tensing up – voluntary or involuntary), Rebound, Rigidity. (G.R.R signs are peritoneal signs – signs of a surgical abdomen).
! Don’t forget to document the location.
Abdominal Detailed
Rectal – Normal Physical Exam
! Document “Chaperone Present”
- Heme Negative
- Brown Stool
- Normal Rectal Tone
Chaperone – Clinical healthcare worker that is the same sex as the patient.
Rectal – Abnormal Physical Exam
- Heme positive (Guaiac positive)
- ANY Abnormal stool color: Black/Melanotic, Red, Yellow, White, Bright Red
- Decreased rectal tone (spinal cord injury)
- Hemorrhoids (Internal, External, Thrombosed)
Female Genital – Normal Physical Exam
! Document “Female Chaperone Present”
- Normal External Genitalia
- Normal Bimanual Exam
- Normal Speculum Exam
- Cervical os is closed
- No blood or discharge
Female Genital – Abnormal Physical Exam
- Sores, Lesions, Rashes
- Cervical motion tenderness (CMT)
- Uterine tenderness
- Adnexal tenderness (Ovaries)
- Cervical Os is open
- Blood in the vaginal vault
- Malodorous/thick white discharge
Male Genital – Normal Physical Exam
! Document “Male Chaperone Present”
- Circumcised OR Uncircumcised
- Testicular Exam WNL
Male Genital – Abnormal Physical Exam
- Testicular Tenderness, Edema, or Mass
- Epididymal Tenderness
- Urethral Discharge
- Inguinal Hernia
- Indwelling Catheter
Musculoskeletal (Extremities) – Normal Physical Exam
- Non-tender
- Full ROM (FROM)
- Distal CSMT (Circulation, Sensory, Motor, Tendon) intact
- No Edema
- No calf tenderness
Musculoskeletal (Extremities) – Abnormal Physical Exam
- Bony tenderness (Fracture)
- Soft tissue tenderness (Contusion)
- Decreased ROM 2° pain
- Pulse/Sensory/Motor deficits Tendon Laxity
- Pitting pedal edema (Trace to 4+)
- Calf tenderness (DVT)
- Palpable cords/Homan’s sign (DVT)
Musculoskeletal (Back) – Normal Physical Exam
- Nontender Thoracic (T-Spine) and Lumbar Spine (L-Spine)
Musculoskeletal (Back) – Abnormal Physical Exam
- Costovertebral Angle (CA) Tenderness
- Paraspinal Tenderness (Muscle Pain) and/or Vertebral Point Tenderness (Spinal Cord Injury)
- Midline Deformities/ Step-Offs
Para- – next to.
Integumentary/Skin – Normal Physical Exam
- Warm (Normal Temperature)
- Dry
- Normal color
- No rashes
- Atraumatic
- No erythema, warmth, or drainage
Integumentary/Skin – Abnormal Physical Exam
- Cool to touch; Hot to touch
- Diaphoretic – Pale appearing
- Jaundice (Yellow), Cyanotic (Blue), Pallor
- Any rash.
- Examples: Urticaria (Hives), Petechiae/Purpura.
- Any sign of trauma.
- Examples: Ecchymosis, Contusion, Abrasion, Laceration, Skin Tear, Avulsion
- Any sign of infection.
- Examples: Erythema, Increased warmth (Calor), Induration (Cellulitis), Fluctuance (Abscess), Purulent Drainage, Lymphangitis (Spreading infection)
Maculopapular rash – red bumps that are flat and raised.
Neurological – Normal Physical Exam (Nonfocal Neuro Exam)
- Alert
- Oriented x4
- Normal Speech
- Is the face symmetrical?
- Cranial Nerves 2-12 Intact
- Nonfocal Neuro Exam
Neurological – Contradictory Abnormal Physical Exam (Nonfocal Neuro Exam)
- Somnolent, Obtunded, Unresponsive
- Disoriented to (person, place, time, or situation)
- Aphasia (Expressive or Receptive) – due to signal from the brain not received properly.
- Slurred speech
- Dysarthria (inability to speak due to motor malfunctions or neural weakness).
- Cranial Nerves – Provider will specify.
- Examples of cranial nerve deficits may be Visual field loss, Unequal pupils, Facial droop, EOM palsy, or facial Hypoesthesia.
- Paraesthesia = Abnormal sensation/Pins and Needles.
Nonfocal (not localized – general neuro exam) Neuro Exam – Any abnormal findings
- *Aphasia** – think language problems.
- *Dysarthria** – think speech problems due to motor/muscles.
- *Expressive aphasia** – “can’t find the right words” (Broca’s).
- *Receptive aphasia** – The right words are being replaced with the wrong output.
Neurological – Normal Physical Exam (Motor and Sensation)
- Motor Strength 5/5 and Symmetric
- Sensation Intact
5/5 – Normal strength
4/5 – Very mildly weak
3/5 – Unable to overcome resistance
2/5 – Unable to overcome gravity
1/5 – Slight contraction, no movement
0/5 – Flaccid, limp
(Effort against force/gravity)
Neurological – Abnormal Physical Exam (Motor and Sensation)
- Extremity Weakness (see chart below)
- Pronator Drift
- Hypoesthesia (decreased sensation)
- Numbness (absent sensation)
- Paraesthesia – Abnormal sensation (usually pins and needles)
Neurological – Reflexes
Deep Tendon Reflexes (DTRs)
0 – Absent
1+ – Hypoactive
2+ – Normal
3+ – Increased
4+ – Unsustained clonus
Neurological – Normal Physical Exam (Cerebellar Exam “Coordination”)
- Normal gait
- No nystagmus
- Normal finger-to-nose
- Normal heel-to-shin
- Negative Romberg’s
Neurological – Abnormal Physical Exam (Cerebellar Exam “Coordination”)
- Ataxia (uncoordinated), Antalgic (walking to avoid pain)
- Nystagmus
- Dysmetria
- Positive Romberg
