Physical Exam Flashcards
General components of exam.
HEENT Neck/Thyroid Pulm CV Abdominal Extremities Neuro
Components of HEENT exam.
Head - inspect, palpate
Eyes - inspect (sclera, conjunctiva), pupils, EOM, fundoscopy, acuity
Ears - external ear (inspect/palpate), TM, Weber, Rinne
Nose - palpate sinuses, inspect with light
Mouth/Throat - inspect with light/tongue depressor
General components of exam.
HEENT Neck/Thyroid/Nodes (head/neck/axillary/epitrochlear/inguinal)/Trachea Pulm CV Abdominal Neuro Extremities/MSK
Components of HEENT exam.
Head - inspect, palpate
Eyes - inspect (sclera, conjunctiva), pupils, EOM, fundoscopy, acuity
Ears - external ear (inspect/palpate), TM (otoscope), Weber, Rinne
Nose - palpate sinuses, inspect with light
Mouth/Throat - inspect with light/tongue depressor
Components of CV exam.
Carotids - palpate, listen Suprasternal notch (palpate) JVD (45 degree angle) Inspect Palpate (PMI) Auscultate Pulses (carotid, femoral, dorsalis pedis, posterior tibial) Edema
Components of Neuro exam?
MSE
CN
Motor (passive ROM, active ROM, strength)
Reflexes
Sensory (sharp, dull, vibration, position sense)
Cerebellum (FNF, heel shin, rapid alternating movements, Romberg, gait)
Babinski
+/- meningeal signs (neck stiffness, Kernig, Brudzinski)
Components of Abdominal exam.
Inspect
Auscultate
Palpate (rebound, liver edge, spleen tip, kidneys)
Percuss liver span
CVA tenderness
+/- obturator sign, psoas sign, Murphy sign
Knee tests?
- Lachman test
- Anterior drawer test
- Posterior draw test
- McMurray test
- MCL/LCL stability
Shoulder tests?
Adduction, internal rotation Abduction, external rotation Neer test Hawkins test Drop arm test O'Brien test
Wrist tests?
Tinel
Phalen
Dupuytren contracture
Heberden nodes
Elbow exam?
Medial and lateral epicondylitis
Hip exam?
Abduction, adduction, flexion, extension
Lower back?
Leg raise test
Lower back?
Leg raise test
Palpate/percuss spine/paravertebrals
HEENT write-up with normal findings?
Head: normocephalic, atraumatic, no lesions/tenderness
Eyes: white sclera, pink conjunctiva, no discharge, EOMI, PERRLA
Fundoscopy: red reflex present, disc round, sharp margins, normal color, vessels normal caliber, no abnormal pigmentation, hemorrhages, exudates, edema, macula visualized
Ears: no lesions, masses, tenderness of external ear, auditory canal without redness, discharge, TMs gray, translucent, with normal light reflex
Nose: pink, no discharge, septum midline, normal turbinates
Mouth/Throat: teeth present and in good dentition, no tongue lesions, moist, no swelling, bleeding, infection, lesions of mucosa, no tonsillar or pharyngeal erythema, exudates, or enlargement
Neck write-up with normal findings?
ROM: normal flexion, extension, lateral rotation, tilting
Trachea; midline, mobile
Thyroid: non-palpable or palpable, normal size and consistency, non-tender, no lesions or nodules
Suprasternal notch: no pulsation
Supple, no JVD, no cervical LAD
Neck write-up with normal findings?
ROM: normal flexion, extension, lateral rotation, tilting
Trachea; midline, mobile
Thyroid: non-palpable or palpable, normal size and consistency, non-tender, no lesions or nodules
Suprasternal notch: no pulsation
Supple, no JVD, no cervical LAD
Lung write-up with normal findings
Percussion: normal resonance to percussion
Auscultation: clear to auscultation bilaterally
No rales, rhonchi, wheezing
No tenderness to palpation
No egophony
Tactile fremitus WNL
Heart write-up with normal findings?
No JVD at 45 degrees
Normal upstroke and amplitude bilaterally of carotids, no bruits
Inspection: no lifts, heaves, PMI not visible
Palpation: no parasternal impulses, thrills, PMI palpable in 5th ICS, MCL, normal size
Ausculation: S1 heard best at apex, normal intensity, S2 heard best at base, normal splitting A2>P2, no extra sounds (S3, S4), no murmurs, rubs, gallops, regular rate, rhythm
Abdomen write-up with normal findings?
Soft, non-tender, non-distended, no guarding or rebound tenderness, no masses, bowel sounds present, no HSM
No scars, striae
Neuro write-up with normal findings?
MS: awake, alert, oriented to person, place, time
CN II-XII grossly intact
Motor: normal tone 5/5 strength in all extremities
Sensory: normal light touch, position sense, vibration, sharp (normal)
Reflexes: 2/4
Negative Babinski
Gait and balance normal
FNF normal, rapid finger mvoements, tandem walking, Romberg etc.
Mental status exam + scoring?
- (5/5) - year, season, date, day, month
- (5/5) - state, county, city, hospital, floor
- (3/3) - name three unrelated objects clearly and slowly, ask the patient to repeat these (registration)
- (5/5) - serials sevens or spell WORLD backwards
- (3/3) - remembers 3 things (recall)
- (2/2) - show two objects, name them
- (1/1) - repeat the phrase “no ifs, ands, or buts”
- (3/3) - take the paper in your right hand, fold it in half, and put it on the floor.
9 (1/1) - Please read this and do what it says (“Close your eyes”) - (1/1) - Write a sentence about anything (noun and verb)
- (1/1) Copy a picture (2 intersecting pentagons)
