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Physical Examination Charting > Physical Examination Charting > Flashcards

Physical Examination Charting Flashcards

1
Q

General Appearance

A

Well nourished, well developed

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2
Q

Cranium

A

Round, atraumatic, normocephalic

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3
Q

Scalp

A

Intact, no masses or lesions

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4
Q

Face

A

Symmetrical, cranial nerve 5 and 7 intact

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5
Q

Sinus Areas

A

Nontender maxillary and frontal

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6
Q

TMJ

A

Full ROM, no crepitus

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7
Q

Visual Acuity

A

Snellen Results; R, L, and bilaterally; cranial nerve 2 intact

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8
Q

Visual Fields

A

Cranial nerve 2 intact

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9
Q

Ocular Movements

A

Cranial nerves 3,4, and 6 intact; smooth, even, EOM’s intact

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10
Q

Ocular Alignment

A

Symmetric, no lag

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11
Q

Lids, lacrimal apparatus

A

No tenderness, no swelling, no discharge

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12
Q

Conjunctiva

A

Pink bilaterally, no discharge

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13
Q

Cornea

A

DNA

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14
Q

Sclera

A

White bilaterally

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15
Q

Lens and media

A

Did not visualize

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16
Q

Pupillary Reflex

A

Cranial nerve 3 intact; PERRLA

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17
Q

Light, direct, and consensual

A

Pupils constrict with light and dilate with dark

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18
Q

Near Point

A

N/A

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19
Q

Fundi

A

vessel visualized bilaterally

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20
Q

Ear external structures

A

pinna symmetric bilaterally

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21
Q

Pre and Post auricular

A

not palpable bilaterally

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22
Q

Ear Canals

A

clear bilaterally

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23
Q

Tympanic membrane

A

translucent bilaterally

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24
Q

Hearing

A

cranial nerve 8 intact; whispered words heard and repeated back correctly bilaterally

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25
Q

Weber

A

able to hear symmetrically

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26
Q

Rinne

A

AC > BC bilaterally

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27
Q

Nasal Septum

A

Midline

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28
Q

Turbinates

A

pink, no discharge

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29
Q

Nasal Mucous membranes

A

Moist

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30
Q

Nasal Patency

A

patent bilaterally

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31
Q

Olfactory Sense

A

Cranial nerve 1 intact; able to smell vanilla bilaterally

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32
Q

Breath

A

No odor

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33
Q

Lips

A

moist, no cracks

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34
Q

Oral Cavity Mucous Membranes

A

moist, intact

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35
Q

Gums

A

Pink, no bleeding

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36
Q

Teeth

A

good dentition

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37
Q

Palates and uvula

A

hard and soft palates no lesions; cranial nerves 9 and 10 intact

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38
Q

Tonsillar areas

A

1+ bilaterally

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39
Q

Oropharynx

A

mucous membranes moist and pink

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40
Q

Tongue

A

cranial nerve 12 intact; good ROM; pink

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41
Q

Oral cavity floor

A

no masses or lesions

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42
Q

Voice

A

good quality

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43
Q

Neck general structure

A

symmetrical

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44
Q

Trachea

A

midline

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45
Q

Thyroid

A

non palpable

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46
Q

Neck lymph nodes

A

not palpable

47
Q

Neck muscles

A

Able to shrug shoulders against resistance; cranial nerve 11 intact

48
Q

Cervical spine, ROM

A

Full ROM

49
Q

Breast general structure

A

right and left symmetrical

50
Q

Areola

A

symmetrical

51
Q

Nipple

A

no deviation

52
Q

Axilla

A

no nodes

53
Q

Chest inspection and palpation

A

Symmetrical; no masses or lesions

54
Q

Chest shape and appearance

A

Symmetric; no barrel chest

55
Q

Type of respiration and rate

A

CTAB (clear to auscultation bilaterally); 80

56
Q

Chest expansion

A

symmetric

57
Q

Fremitus

A

palpable symmetrically

58
Q

Chest Percussion

A

Resonance throughout

59
Q

Resonance

A

Throughout symmetrically

60
Q

Diaphragmatic Excursion

A

3-4

61
Q

Chest Auscultation

A

CTAB

62
Q

Breath Sounds

A

Pitch: high
Intensity: Loud
Quality: harsh, hollow, tubular
Duration: inspiration < expiration

63
Q

Cardiovascular Rate and Rhythm

A

RRR

64
Q

PMI

A

no thrills

65
Q

Cardiac Sounds

A

S1 - heard
S2 - heard
S3 - none
S4 - none

66
Q

Extra Sounds

A

no

67
Q

Murmur

A

no

68
Q

Carotids

A

2+ bilaterally

69
Q

Jugular Venous Pulse and Pressure

A

DNA

70
Q

Description of Peripheral Pulses

A

2+ bilaterally

71
Q

Abdomen Contour and Tone

A

Flat

72
Q

Abd Scars, Lesions

A

None

73
Q

Liver

A

Non palpable

74
Q

Spleen

A

Non palpable

75
Q

Kidneys

A

Non palpable

76
Q

Bladder

A

No distention

77
Q

Hernias

A

None

78
Q

Abd Masses

A

None

79
Q

Abd Tenderness

A

None

80
Q

Abd Percussion Sounds

A

Tympany

81
Q

Vulva

A

No masses or lesions

82
Q

Batholin’s gland-urethra and skenes

A

No masses or lesions

83
Q

Vagina

A

Pink, moist

84
Q

Cervix

A

Pink, nulliparous

85
Q

Uterus

A

Non tender

86
Q

Adnexa

A

Non tender

87
Q

Pelvic musculature

A

Good

88
Q

Rectal external structure

A

No masses or lesions

89
Q

Sphincter Tone

A

Good

90
Q

Rectal Masses

A

None

91
Q

Prostate

A

N/A

92
Q

Stool

A

brown

93
Q

Extremities general appearance

A

symmetrical

94
Q

Gait

A

smooth, steady

95
Q

Joints

A

no crepitus, full ROM

96
Q

Epitrochlear nodes

A

none noted

97
Q

Extremities ROM

A

full ROM bilaterally

98
Q

Muscle strength

A

5/5 bilaterally

99
Q

Muscle Mass

A

even

100
Q

Spine contour

A

straight, midline

101
Q

Spinal ROM

A

full

102
Q

Vertebral Joints

A

no crepitus

103
Q

CVA Tenderness

A

None

104
Q

Mental Status

A

alert, oriented

105
Q

Language

A

English

106
Q

Cranial Nerves

A

1-12 intact

107
Q

Motor Coordination (Upper and Lower)

A

Smooth bilaterally

108
Q

Involuntary Movements

A

none

109
Q

Romberg

A

Negative

110
Q

DTR’s

A

2+

111
Q

Light touch

A

able to feel dull

112
Q

Pain

A

able to feel sharp

113
Q

Vibration

A

DNA

114
Q

Position

A

Rapid alternating

Physical Examination Charting (1 decks)

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