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Scribing > Physical Exam > Flashcards

Physical Exam Flashcards

1
Q

Benign Exam - Constitutional

A

Well developed, well nourished.
No acute distress.
Alert

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2
Q

Benign Exam - Eyes

A

PERRL
EOMI (touch)
Sclera are anicteric (normal)
Normal conjuctiva

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3
Q

Benign Exam - Mouth

A

Moist mucous membranes

Oropharynx (OP) normal

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4
Q

Benign Exam - Neck

A

Supple, No lymphadenopathy (touch)

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5
Q

Benign Exam - Cardiovascular

A

Well perfused. Regular rate and rhythm (touch),
No murmurs, rubs, or gallops (touch).
Distal pulses intact (touch).

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6
Q

Benign Exam - Respiratory

A

No respiratory distress.
Clear to ausultation bilaterally (CTAB) (touch).
No wheezes, rales, or rhonchi (touch).

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7
Q

Benign Exam -Abdominal

A

Non-distended. Soft (touch).
Non-tender (touch).
No guarding, rebound, or rigidity (touch).

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8
Q

Benign Exam - Extremities

A

No edema, Full ROM (touch)

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9
Q

Benign Exam - Skin

A

Dry, no rashes. Warm (touch)

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10
Q

Benign Exam - Neurological (Non-Focal Neuro Exam)

A

Alert and oriented (A&Ox4) }
Normal speech. }-Non-Focal Neuro Exam
Motor Strength 5/5 and Symmetric
Deep Tendon Reflex (DTR) 2+

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11
Q

Benign Exam - Psychiatric

A

Normal affect.

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12
Q

Abnormal Exam - Constitutional

A

Mild/moderate/severe distress
Cachectic/emaciated/malnourished
Somnolent, obtunded, unresponsive

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13
Q

Benign Exam - Head

A

Atraumatic/normocephalic (AT/NC)

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14
Q

Abnormal Exam - Head

A

Any signs of trauma
Sinus tenderness
Angioedema (facial swelling)

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15
Q

Abnormal Exam - Eyes

A

Anisocoria (unequal pupils)
EOM entrapment (mvmt stopped)
Sclera icterus
Pale conjunctiva or conjunctival injection

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16
Q

Abnormal Exam - Detailed Eye and Instruments

A

Retinal detachment - Ophthalmoscope
Papilledema
Hyphema
Coneal Abrasion or Ulcerations - Wood’s Lamp or Fluorescein uptake

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17
Q

Benign Exam - Detailed Eye

A

Clear anterior chamber
Sharp disk margins
Normal cornea

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18
Q

Abnormal Exam - Ears

A

TM erythema
TM bulging
TM dullness (infected)
TM obscured by cerumen (earwax)

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19
Q

Benign Exam - Ears

A

TMs Normal

20
Q

Abnormal Exam - Nose

A 
Epistaxis
Rhinorrhea
Septal hematoma
Boggy turbinates
Nasal deformity
21
Q

Benign Exam - Nose

A

Normal Nares. (naris - singular)

22
Q

Abnormal Exam - Mouth

A 
Dry Muccous Membranes (DMM)
Dental Caries
Edentulous (no teeth)
Pharyngeal Erythema
Tonsilar Exudate
Tonsillar Hypertrophy
Peritonsillar Abscess (PTA)
23
Q

Abnormal Exam - Neck and C-Spine

A 
JVD
Carotid bruit
Cervical lymphadenopathy
Vertebral Point vs. Paraspinal Tenderness
Thyromegaly
Nucal Rigidity, meningismus, limited ROM
24
Q

Abnormal Exam - Cardiovascular

A 
Tachycardia/Bradycardia
Irregular Irregular Rhythm
Murmur
Extrasystoles
Pleural Rub
Gallop
25
Q

Abnormal Exam - Perfusion

A

Delayed capillary refill

0=absent,1+=Barely palpable,2+=Easily palpable,3+=Full,4+=Bounding/aneurysmal

26
Q

Abnormal Exam - Pulmonary

A 
Mild/Moderate/Severe Respiratory Distress
Tachypnea
Accessory muscle use
Diminished breath sounds
Wheezes (inspiratory/expiratory)
Rales (crackles)
Rhonchi
27
Q

Abnormal Exam - Abdominal

A

Mild/mod/severe Tenderness to Palpation (TTP)
Voluntary Guarding }
Rebound Tenderness }- Peritoneal Signs
Rigidity (involuntary guarding) }

28
Q

Abnormal Exam - Abdominal Detailed

A

Absent/Hypoactive/Hyperactive Bowel Sounds
Organomegaly (Hepato or spleno)
Distended
Murphy’s Sign
McBurney’s point tenderness }
Psoa’s sign, Obturators, Rovsing’s}-Appendicitis Signs

29
Q

Abnormal Exam - Rectal

A

Heme Positive (Guaiac positive)
Abnormal stool color: Black/Melanoic, red, yellow, white, bright red
Hemorrhoids (internal, external, thrombosed)
Rectal prolapse
Decreased rectal tone (spinal chord injury)

30
Q

Abnormal Exam - Female Genital

A

Sores, Lesions, Rashes
Cervical motion tenderness (CMT), uterine tenderness, adenexal tenderness (ovaries
Cervical Os is open, blood in vaginal vault, malodorous/thick white discharge

31
Q

Abnormal Exam - Male Genital

A 
Testicular tenderness, edema, mass
Epidiymal tenderness
Urethral discharge
Inguinal hernia
Indwelling catheter
32
Q

Abnormal Exam - Musculoskeletal/extremities

A

Bony tenderness (fractures),Soft tissue tenderness (contusion), calf tenderness (DVT)
Decreased ROM secondary to pain
Pulse/sensory/motor deficits/tendon laxity
Pitting pedal edema (trace to 4+)
Palpable cords/homan’s sign (DVT)

33
Q

Abnormal Exam - Musculoskeletal/back

A 
CVA Tenderness
Paraspinal Tenderness (muscle pain)
Vertebral Point Tenderness (spinal cord injury)
Midline deformities/step-offs
34
Q

Abnormal Exam - Integumentary

A

Cool/hot to touch
Diaphoretic
Jaundice, cyanotic, pallor
Urticaria, petechiae/purpura

35
Q

Abnormal Exam - Skin Infection

A

Erythema, increased warmth (calor), induration (cellulitis), fluctuance (abscess), purulent drainage (pus-like), lymphangitis (spreading infection)

36
Q

Abnormal Exam - Skin Trauma

A

Ecchymosis, contusion, abrasion, laceration, skin tear, avulsion

37
Q

Abnormal Exam - Neurological

A

Somnolent
Disoriented to person,place,time,situation
Aphasia (expressive/receptive), dysarthria (slurring)

38
Q

Abnormal Neurological Level of Consciousness

A

Somnolent, obtunded, responsive to voice, responsive to painful stimuli, unresponsive, does not follow commands

39
Q

Abnormal Neurological Motor and Sensation

A

Extremity weakness: 0=flacid/limp,1=slight contraction, no mvmt,2=unable to overcome gravity,3=unable to overcome resistance,4=very mildly weak
Pronator drift
Hypoesthesia (decreased sensation)
Numbness (absent sensation)

40
Q

Abnormal Neurological Reflexes

A

Deep tendon reflexes (DTRs)
0=absent,1+=hypoactive,2+=normal,3+=increased,4+=unsustained clonus
Babinski: Upgoing toes (normal=downgoing toes)

41
Q

Abnormal Neurological Cranial Nerve Exam

A 
Visual field loss
Unequal pupils (anisocoria)
EOM palsy, Rightward/leftward gaze
Tongue deviation
Decreased gag reflex
Facial droop, ptosis 
Hyposthesia, numbness
Unequal shoulder shrug
42
Q

Abnormal Neurological Cerebellar Exam “Coordination”

A 
Ataxia (unsteady), antalgic
Nystagmus (eyes vibrating)
Dysmetria (finger-to-nose, heel-to-shin)
Positive Romberg (stand w/ eyes closed)
Dysdiadochokinesia (rapid alternating movements)
Tremor
43
Q

Abnormal Exam - Psychiatric

A

Flat/odd affect, tearful, anxious, depressed, hypomanic, poor eye contact
Suicidal/homicidal, hallucinations, flight of ideas, paranoid
Denies illness/Sx, non-compliant with treatment
Tangential speech, pressured speech

44
Q

Abnormal Exam - Trauma
Head,eyes,ears,nose,oropharynx,neck,
respiratory,abd,rectal,musculoskeletal,back,skin,neurological

A

Battle’s sign, racoon eyes, periorbital ecchymosis
Unequal pupils, subconjuctival hemorrhage, hyphema
Hemotympanum
Nasal bone deformity, epistasis, septal hematoma
Malocclusion, dental injury
Vertebral point tenderness, deformities, step-offs
Absent breath sounds, splinting, crepitus
Tenderness, distended, ecchymoses
Rectal laxity
Pelvis unstable, bony tenderness, deformity
Vertebral point tenderness, deformities, step-offs
Ecchymosis, laceration, abrasion,skin tear, avulsion
Glasgow Coma Scale

45
Q

Code Exam

General, head, eyes, oropharynx, cardiovascular, respiratory, abd, musculoskeletal, skin, neurological

A 
Unresponsive
Normocephalic, Atraumatic
Fixed and Dilated
Airway patent, ETT in place
Absent heart sounds, no palpable pulses
No spontaneous respirations, equal with controlled ventilation
Distended
No deformities
Pallor,cyanotic,mottled
Unresponsive
46
Q

Abnormal Pediatric Exam

A

Lethargic (only if Dr. states)
Sunken fontanel, bulging fontanel (normal=flat)
Wheezes, stridor, retractions, nasal flaring
Crying with normal abd palpation

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