Physical Exam Findings Flashcards
What 4 things do you document under General Constitutional?
1) Appearence (Normal = NAD or Appearance is normal)
2) Nourishment/Development (Normal = Well Nourished/Well-Developed)
3) Alertness (Normal = Oriented to time, place, and person)
4) Affect (Normal = Mood normal, Affect normal)
What 6 things do you document under Integumentary System?
1) Skin temperature (Normal = Normal Skin Temperature)
2) Skin wet/dry (Normal = Skin is dry to touch)
3) Color (Normal = Normal color)
4) Rashes (Normal = No rash)
5) Skin intact (Normal = Skin is intact)
6) Signs of Infections (Normal = No signs of infections)
What 3 things do you document on the head?
1) Signs of trama (Normal = Atraumatic, normocephalic)
2) Face appearance (Normal = Face is grossly normal)
3) Fontanelle (on peds) (Normal = Normal Fontanelle)
What 6 things do you document on eyes?
1) Reaction to light (Normal = PERRL)
2) Eye muscles (Normal = EOMI)
3) Conjunctiva (Normal = Normal conjunctiva)
4) Schlera (Normal = Normal sclera)
5) Cornea (Normal = Normal cornea)
6) Eyelids and lashes (Normal = Eyelids and lashes appear normal)
What 3 things do you document on ears?
1) TM’s
2) External Canals
3) Pinna
What 4 things do you document on nose?
1) Nasal mucosa
2) Nasal discharge
3) Septum
4) Nostrils
What 6 things do you document on oral pharynx/throat?
1) Lips/tongue
2) Oral mucosa
3) Posterior pharynx
4) Normal appearing tonsils
5) Normal dentition
6) Normal voice
What 5 things do you document on the neck?
1) Appearance
2) ROM
3) Any palpable lymphadenopathies
4) Any thyromegalies
5) Any JVD or cartotid bruit
What 4 things do you note in chest/lungs?
1) Any respiratory distress
2) Appearance and symmetry of chest
3) Lung sounds (Normal = clear)
4) Palpation findings (Normal = Normal to palpation)
What 4 things do you document in Cardiac?
1) Auscultation and rate rhythm (Normal = Heart is normal to auscultation and Regular rate and rhythm)
2) Symmetry of peripheral pulses
3) Any Edema
How is edema measured?
From Trace to 4+ pitting edema.
What 4 things are documented in Abdominal?
1) Appearance
2) Results of palpation
3) Bowel sounds
4) Any CVA tenderness
SI
Suicidal Ideation
HI
Homicidal Ideation
What should you note if a patient is positive for SI or HI?
If they are with or without a plan?
Where is Flight of ideas noted?
In Psychiatric under thought processes
Which sections are not normally selected in the general adult physical template?
1) Psychiatric
2) Genitourinary
3) Abdominal
On what scale is strength measured in the motor skills section of Neurogical? What is normal strength?
1-5 out of 5 ; 5/5 is normal strength.
Which tendons are most commonly checked in DTR test?
Patella, Achilles, and Biceps
What is Homan’s sign used to diagnose?
Thrombosis in lower leg
Where is Homan’s sign documented/
Musculoskeletal
Where are Valgus and Varus tests documented? What do they test?
Musculoskeletal; Valgus = ligament damage, Varus=joint laxity on outside of knee
What is McMurray’s test? Where is it documented?
Tests for damage to meniscus of knee; documented in Musculoskeletal
What 5 tests are documented in Abdominal findings?
1) Murphy’s sign (gall bladder)
2) McBurney’s Sign (appendix)
3) Psoas Sign (Appendix)
4) Obturator’s Sign (Appendix)
5) Rovsing’s Sign (Appendix)
Where is edema noted?
Cardiac findings
What does bibasilar mean?
At the base of both lungs
What tests are documented in Neck?
1) Kernig’s Sign
2) Brudzinski’s Sign
What is a benign, painless bump on the eyelid?
Chalazion
Where is Hordeolum documented? What is it?
Eyes; an infection of the eyelid
What kind of rashes disappear when pressed?
Blanching
What kind of rashes do not disappear when pressed?
Non-blanching
