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Scribe America > Physical Exam > Flashcards

Physical Exam Flashcards

1
Q

Do any patient complaints belong in the PE?

A

No

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2
Q

If a patient says their abdomen feels very painful, can you automatically document “abdominal tenderness” in the PE? Why or Why Not?

A

No. it is subjective.

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3
Q

Which of these two physical findings could a physician appreciate without auscultating patient lungs:

a) No respiratory distress
b) No rales

A

a) No respiratory distress

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4
Q

What does PEERL stand for?

A

Pupils are equal, round, and reactive to light

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5
Q

What does NAD stand for?

A

No acute distress

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6
Q

What does AT/NC mean?

A

atraumatic/normocephalic

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7
Q

If a pt has pale conjunctiva, what does that indicate?

A

GI Bleed

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8
Q

What is scleral icterus, and what does it indicate?

A

yellow sign of liver failure

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9
Q

Name an instrument a physician may use to closely investigate the eyes.

A

Ophthalmoscope

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10
Q

In which body system would you document “TM erythema and bulging”?

A

ENT

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11
Q

What is the medical term for nostril?

A

Nares

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12
Q

To describe a “runny nose” would the doctor use the word “epistaxis” or “rhinorrhea”

A

Rhinorrhea

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13
Q

What would dry mucous membranes indicate?

A

dehydration

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14
Q

Why is midline body tenderness “worse” than paraspinal tenderness?

A

Bony tenderness (aka vertebral point tenderness) points toward a spinal fracture and therefore concern for spinal cord injury. paraspinal tenderness points toward a muscle sprain or strain

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15
Q

If you saw “RRR” written in the cardiac exam, what do you think it might mean?

A

Regular Rate & Rhythm

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16
Q

If the physican checks the pulse on the right right wrist and says “The pulses are fine”, what would you document in the physical exam?

A

Right Radial pulse is 2+

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17
Q

Name the rhythm that the physical would hear if the patient was in Afib

A

Irregularly Irregular

18
Q

Name two “Peritoneal signs” in the abdominal exam

A
  1. Voluntary Guarding
  2. Rebound Tenderness
  3. Rigidity (Involuntary Guarding)
19
Q

What abdominal exam sign is indicative of Cholecystitis

A

Murphy’s Sign

20
Q

If a doctor takes 1 finger and presses in a specific spot in the RLQ, what is the name of the finding they are investigating

A

McBurney’s point tenderness

21
Q

Which of these findings is NOT a peritoneal signs?

Guarding, Rebound, Tenderness, Rigidity

A

Tenderness

22
Q

What would a “Guaiac positive” stool sample diagnose

A

GI Bleed

23
Q

What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician?

A

Female Chaperone Present

24
Q

What is bony tenderness a sign of?

A

Bone deformity, fracture, or injury

25
Q

What is CVA tenderness?

A

Flank tenderness (costovertebral angle tenderness). Tenderness over the kidneys

26
Q

What is fluctuance a sign of?

A

Abscess

27
Q

What is the difference between a laceration and abrasion

A

Laceration-incision in the skin that typically need sutures

Abrasion-scrape of the skin

28
Q

What procedure is associated with a laceration, but not an abrasion?

A

Laceration Repair, Sutures

29
Q

What does A & Ox3 mean?

A

Alert and oriented to person, place, and time

30
Q

What section of the neurological exam would you document “Normal Finger-Nose-Finger test” and “Normal Heel to Shin”?

A

Cerebellar/Coordination

31
Q

What does DTR stand for?

A

Deep Tendon Reflex

32
Q

Point to the general area of your body that Cranial Nerves control.

A

Face

33
Q

In the Neurological exam, what does “Normal gait” mean?

A

Walking normally

34
Q

In the psychiatric exam, what do SI and HI stand for?

A

Suicidal and Homicidal ideations

35
Q

is the Glascow Coma Scale associated with Trauma its or Medical patients

A

Trauma

36
Q

Would you document “RUE strength 3/5” under the Neurological or Extremities section of the exam

A

Neurological

37
Q

What would you guys TTP means?

A

Tender to palpation

38
Q

A mother states her child has been extremely tired and drowsy recently; based on that, can you document “Lethargic” in the child’s physical exam?

A

No!

39
Q

Spell the medical term for Hives (allergic reaction rash)

A

Urticaria

40
Q

What is the medical term for Swollen lymph nodes

A

Lymphadenopathy

41
Q

If you document “There is right pronator drift” in the neurological exam, can you also document “No focal neurological deficits”?

A

No. Contradiction

42
Q

If you documented “NAD” in the constitutional section, would you be contradicting yourself if you wrote “There is mild respiratory distress” in the pulmonary exam?

A

Yes

Scribe America (11 decks)

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