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Scribe stuff > Physical exam terminology > Flashcards

Physical exam terminology Flashcards

1
Q

Nml *general/constitutional

A

well developed, well nourished. no acute distress

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2
Q

*eyes Nml

A

PERRL, EOMI

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3
Q

*ENT Nml

A

moist musous membranes
ears-tympanic membranes (TM’s) normal
nose- normal nares(nostrils, singular naris)
throat- oropharynx (OP) normal

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4
Q

*neck Nml

A

supple, no lymphadenopathy

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5
Q

*cardiovascular Nml

A

regular rate and rhythm. no murmurs, rubes or gallops. distal pulses intact. (external- well profused/”moving air”

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6
Q

*respiratory Nml

A

no respiratory distress. clear to auscultation bilaterally. no wheezes, rales or rhochi

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7
Q

*abdominal Nml

A

soft. non-tender. no guarding , rebound or rigidity

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8
Q

*extremities Nml

A

no edema, full ROM

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9
Q

*skin Nml

A

warm and dry

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10
Q

*neurological Nml

A

alert and oriented normal speech

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11
Q

*psychiatric Nml

A

normal affect

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12
Q

head Nml

A

atraumatic normocephalic (AT/NC)

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13
Q

–general constitutional

A

mild/moderate. severe distress due to pain

cachetic/emaciated/malnourished

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14
Q

–head

A

sinus tenderness

angioedema

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15
Q

—eyes

A

scleral Icterus
pale conjunctiva
conjunctival injection

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16
Q

—-Ears

A

TM erthema
TM bulging
TM dullness
TM obscured by cerumen (ear wax)

17
Q

—-Nose

A

epistaxis
rhinorrhea
septal hematoma
boggy turbinates (swollen inner nose)

18
Q

——-Mouth/throat

A 
dry mucous membranes (DMM)
dental cavities
edentulous
*pharyngeal erythema
tonsillar exudate
tonsillar hypertrophy
peritonsillar abscess (PTA)
19
Q

—–neck and cervical spine

A 
jugular venous distension (JVD)
carotid bruit
cervical lymphadenopathy (swollen lymph nodes)
verebral point vs paraspinal tenderness
thyromegaly
20
Q

——cardiovscular (CV)

A 
tachycarida >100 or bradycardia <60
irregularly irregular rhythm...no AFib
murmur
extrasystoles (extra beats)
pleural rub
gallop
dont contradict rate finding and rhythm findings
21
Q

*Perfusion

A

pulse places: radial carotid, femoral, Dorsalis PEdis (DP), posterior tibialis(PT)
0-4+ with 2+being normal

22
Q

——-pulmonary

A 
mild/moderate/severe respiratory distress
tachypnea
accessory muscle use
diminished breath sounds
wheezes(inspiratory or expiratory
Rales(crackles)
rhonchi
*don't contradict respiratory distress and auscultation findings
23
Q

—-abdominal

A

mild/mod/severe tenderness
voluntary guarding
rebound tenderness
rigidity(involuntary guarding)

24
Q

Abdominal detailded

A 
absent/hypoactive/hyperactive bowel sounds
organomegaly
distended
Murphy's sign
McBurney's point tenderness
psoa's sign, obturators, rovsing's
25
Q

Male genital

A 
testicular tenderness
epididymal tenderness
testicular edema
testicular mass
urethral discharge
inguinal hernia
26
Q

musculoskeletal/extremeties

A 
bony tenderness
tendon laxity
decreased ROM 2º  of pain
*pitting pedal edema (trace to 4+)
calf tenderness
Palpable cords/ Homan's sign
27
Q

back

A

CVA tenderness
paraspinal tenderness
Vertebral point tenderness
midline deformities/step offs

28
Q

skin

A 
pallor
cyanosis
jaundice
diaphoresis
urticaria
petechiae/pupura
29
Q

skin infection

A 
Erythema-redness
increased warmth (calor)
induration (cellulitis) (swelling
Fluctuance (abscess)
Purulent Drainage
Lymphangitis
30
Q

skin trauma

A 
ecchymosis-bruise
contusion- severe bruise
abrasion
laceration (size in cm)
skin tear (old people)
Avulsion
31
Q

nuerological basic

A

somnolent- abnormal drowsiness
disoriented to (person, place, time or situation)
Aphasia (expressive or receptive) (speech probs)
dysarthria
any abnormal findings

32
Q

neurological motor and sensation

A

extremity weakness (0-5 with 5 being normal)
Pronator drift
Hypoesthesia (decreased sensation)
numbness

33
Q

neurological reflexes

A

testing deep tendon reflexes (DTRs) in tricepts, bicepts, brachioradialls, patellar, achhilles,; range from 0-4+ with 2 being normal
babinski is normal if downing toes, abnormal if upgoing toes

34
Q

neurological cranial nerve exam

A 
visual field loss 
unequal pupils
EOM palsy, righforwar/leftforward gaze
tongue deviation
decreased gag reflex
 facial droop,ptosis
hypoesthesia, numbness
unequal shoulder shrug
35
Q

neurological cerebellar

A 
atazia 
nystagmus
dysmetriaa
positive Romberg
dysdiadochokinesia
tremor
36
Q

psychiatric

A 
flat affect/odd affect
tearful
anxious
depressed 
hypomanic
poor eye contact
paranoid
hallucinations (auditory or visual)
Flight of ideas (loose associations)
tangential speech
Suicidal or homicidal (with or without plan)

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