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Scribe America ED > Physical Exam > Flashcards

Physical Exam Flashcards

1
Q

Benign

A

Not harmful

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2
Q

Anatomical Position

A

A frame of reference used to describe anatomy and movement.

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3
Q

Tenderness

A

Pain felt upon palpation.

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4
Q

Icterus

A

Yellowing, also known as jaundice.

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5
Q

Purulent

A

Pus-like

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6
Q

Erythema

A

Redness

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7
Q

Organomegaly

A

Organ enlargement

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8
Q

Perfusion

A

The flow of blood through the body’s blood vessels.

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9
Q

Affect

A

The patient’s immediate expression of emotion.

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10
Q

Consolable

A

Able to be comforted.

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11
Q

GCS

A

Glasgow Coma Exam – used to assess the level of consciousness in trauma pts.

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12
Q

General/Constitutional – Normal Physical Exam

A
  • No Acute Distress (NAD) – comfortable appearing.
  • Well-developed, Well-nourished.
  • Alert
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13
Q

General/Constitutional – Abnormal Physical Exam

A
  • 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.

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14
Q

Head – Normal Physical Exam

A

Atraumatic/Normocephalic (AT/NC)

“a” – without

-cephalic – head

Peri- – around

Periorbital – around the eyes.

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15
Q

Head – Abnormal Physical Exam

A
  • Any signs of trauma
  • Sinus tenderness
  • Angioedema
  • Allergic reaction

Angioedema – swelling of the eyes, lips, throat, or tongue.

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16
Q

Eyes – Normal Physical Exam

A
  • 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.

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17
Q

Eyes – Abnormal Physical Exam

A
  • 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).

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18
Q

Ears/Throat – Normal Physical Exam

A
  • Tympanic Membranes (TMs) Normal
  • Moist Mucous Membranes
  • Oropharynx (OP) Normal
  • Normal dentition
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19
Q

Ears/Throat – Abnormal Physical Exam

A
  • 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.

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20
Q

Neck and Cervical Spine – Normal Physical Exam

A
  • Nontender Cervical Spine (C-Spine)
  • Supple (free movement of a body part)
  • Normal appearance and normal ROM (range of motion).
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21
Q

Neck and Cervical Spine – Abnormal Physical Exam

A
  • 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.

22
Q

Cardiovascular (CV) – Normal Physical Exam

A
  • 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).

23
Q

Cardiovascular (CV) – Abnormal Physical Exam

A
  • 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).

24
Q

Perfusion – Physical Exam

A

The flow of blood through the body’s blood vessels.

  • Radial Pulse
  • Carotid Pulse
  • Femoral Pulse
  • Dorsalis Pedis (DP) Pulse
  • Posterior Tibial (PT) Pulse
25
Q

Perfusion – Documentation

A

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.

26
Q

Pulmonary – Normal Physical Exam

A
  • No respiratory distress
  • Normal respiratory rate
  • Normal effort
  • Breath Sounds Clear and Equal
27
Q

Pulmonary – Abnormal Physical Exam

A
  • 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
28
Q

Pulmonary – Contradictions

A

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)
29
Q

Abdominal – Normal Physical Exam

A
  • Soft
  • Non-tender
  • No peritoneal signs
30
Q

Abdominal – Abnormal Physical Exam

A
  • 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.

31
Q

Abdominal Detailed

A
32
Q

Rectal – Normal Physical Exam

! Document “Chaperone Present”

A
  • Heme Negative
  • Brown Stool
  • Normal Rectal Tone

Chaperone – Clinical healthcare worker that is the same sex as the patient.

33
Q

Rectal – Abnormal Physical Exam

A
  • 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)
34
Q

Female Genital – Normal Physical Exam

! Document “Female Chaperone Present”

A
  • Normal External Genitalia
  • Normal Bimanual Exam
  • Normal Speculum Exam
  • Cervical os is closed
  • No blood or discharge
35
Q

Female Genital – Abnormal Physical Exam

A
  • 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
36
Q

Male Genital – Normal Physical Exam

! Document “Male Chaperone Present”

A
  • Circumcised OR Uncircumcised
  • Testicular Exam WNL
37
Q

Male Genital – Abnormal Physical Exam

A
  • Testicular Tenderness, Edema, or Mass
  • Epididymal Tenderness
  • Urethral Discharge
  • Inguinal Hernia
  • Indwelling Catheter
38
Q

Musculoskeletal (Extremities) – Normal Physical Exam

A
  • Non-tender
  • Full ROM (FROM)
  • Distal CSMT (Circulation, Sensory, Motor, Tendon) intact
  • No Edema
  • No calf tenderness
39
Q

Musculoskeletal (Extremities) – Abnormal Physical Exam

A
  • 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)
40
Q

Musculoskeletal (Back) – Normal Physical Exam

A
  • Nontender Thoracic (T-Spine) and Lumbar Spine (L-Spine)
41
Q

Musculoskeletal (Back) – Abnormal Physical Exam

A
  • Costovertebral Angle (CA) Tenderness
  • Paraspinal Tenderness (Muscle Pain) and/or Vertebral Point Tenderness (Spinal Cord Injury)
  • Midline Deformities/ Step-Offs

Para- – next to.

42
Q

Integumentary/Skin – Normal Physical Exam

A
  • Warm (Normal Temperature)
  • Dry
  • Normal color
  • No rashes
  • Atraumatic
  • No erythema, warmth, or drainage
43
Q

Integumentary/Skin – Abnormal Physical Exam

A
  • 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.

44
Q

Neurological – Normal Physical Exam (Nonfocal Neuro Exam)

A
  • Alert
  • Oriented x4
  • Normal Speech
  • Is the face symmetrical?
  • Cranial Nerves 2-12 Intact
  • Nonfocal Neuro Exam
45
Q

Neurological – Contradictory Abnormal Physical Exam (Nonfocal Neuro Exam)

A
  • 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.
46
Q

Neurological – Normal Physical Exam (Motor and Sensation)

A
  • 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)

47
Q

Neurological – Abnormal Physical Exam (Motor and Sensation)

A
  • Extremity Weakness (see chart below)
  • Pronator Drift
  • Hypoesthesia (decreased sensation)
  • Numbness (absent sensation)
  • Paraesthesia – Abnormal sensation (usually pins and needles)
48
Q

Neurological – Reflexes

A

Deep Tendon Reflexes (DTRs)
0 – Absent
1+ – Hypoactive
2+ – Normal
3+ – Increased
4+ – Unsustained clonus

49
Q

Neurological – Normal Physical Exam (Cerebellar Exam “Coordination”)

A
  • Normal gait
  • No nystagmus
  • Normal finger-to-nose
  • Normal heel-to-shin
  • Negative Romberg’s
50
Q

Neurological – Abnormal Physical Exam (Cerebellar Exam “Coordination”)

A
  • Ataxia (uncoordinated), Antalgic (walking to avoid pain)
  • Nystagmus
  • Dysmetria
  • Positive Romberg

Scribe America ED (13 decks)

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