Physical exam terminology

Question 1

Nml *general/constitutional

Answer 1

well developed, well nourished. no acute distress

Question 2

*eyes Nml

Answer 2

PERRL, EOMI

Question 3

*ENT Nml

Answer 3

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

Question 4

*neck Nml

Answer 4

supple, no lymphadenopathy

Question 5

*cardiovascular Nml

Answer 5

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

Question 6

*respiratory Nml

Answer 6

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

Question 7

*abdominal Nml

Answer 7

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

Question 8

*extremities Nml

Answer 8

no edema, full ROM

Question 9

*skin Nml

Answer 9

warm and dry

Question 10

*neurological Nml

Answer 10

alert and oriented normal speech

Question 11

*psychiatric Nml

Answer 11

normal affect

Question 12

head Nml

Answer 12

atraumatic normocephalic (AT/NC)

Question 13

–general constitutional

Answer 13

mild/moderate. severe distress due to pain

cachetic/emaciated/malnourished

Question 14

–head

Answer 14

sinus tenderness

angioedema

Question 15

—eyes

Answer 15

scleral Icterus
pale conjunctiva
conjunctival injection

Question 16

—-Ears

Answer 16

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

Question 17

—-Nose

Answer 17

epistaxis
rhinorrhea
septal hematoma
boggy turbinates (swollen inner nose)

Question 18

——-Mouth/throat

Answer 18

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

Question 19

—–neck and cervical spine

Answer 19

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

Question 20

——cardiovscular (CV)

Answer 20

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

Question 21

*Perfusion

Answer 21

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

Question 22

——-pulmonary

Answer 22

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

Question 23

—-abdominal

Answer 23

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

Question 24

Abdominal detailded

Answer 24

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

Question 25

Male genital

Answer 25

``` testicular tenderness epididymal tenderness testicular edema testicular mass urethral discharge inguinal hernia ```

Question 26

musculoskeletal/extremeties

Answer 26

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

Question 27

back

Answer 27

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

Question 28

skin

Answer 28

``` pallor cyanosis jaundice diaphoresis urticaria petechiae/pupura ```

Question 29

skin infection

Answer 29

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

Question 30

skin trauma

Answer 30

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

Question 31

nuerological basic

Answer 31

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

Question 32

neurological motor and sensation

Answer 32

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

Question 33

neurological reflexes

Answer 33

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

Question 34

neurological cranial nerve exam

Answer 34

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

Question 35

neurological cerebellar

Answer 35

``` atazia nystagmus dysmetriaa positive Romberg dysdiadochokinesia tremor ```

Question 36

psychiatric

Answer 36

``` 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) ```