Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Physical Examination Charting > Physical Examination Charting > Flashcards

Physical Examination Charting Flashcards

1
Q

General Appearance

A

Well nourished, well developed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Cranium

A

Round, atraumatic, normocephalic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Scalp

A

Intact, no masses or lesions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Face

A

Symmetrical, cranial nerve 5 and 7 intact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Sinus Areas

A

Nontender maxillary and frontal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

TMJ

A

Full ROM, no crepitus

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Visual Acuity

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Visual Fields

A

Cranial nerve 2 intact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Ocular Movements

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Ocular Alignment

A

Symmetric, no lag

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Lids, lacrimal apparatus

A

No tenderness, no swelling, no discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Conjunctiva

A

Pink bilaterally, no discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Cornea

A

DNA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Sclera

A

White bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Lens and media

A

Did not visualize

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Pupillary Reflex

A

Cranial nerve 3 intact; PERRLA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Light, direct, and consensual

A

Pupils constrict with light and dilate with dark

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Near Point

A

N/A

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Fundi

A

vessel visualized bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Ear external structures

A

pinna symmetric bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Pre and Post auricular

A

not palpable bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Ear Canals

A

clear bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Tympanic membrane

A

translucent bilaterally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Hearing

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Weber
able to hear symmetrically
26
Rinne
AC > BC bilaterally
27
Nasal Septum
Midline
28
Turbinates
pink, no discharge
29
Nasal Mucous membranes
Moist
30
Nasal Patency
patent bilaterally
31
Olfactory Sense
Cranial nerve 1 intact; able to smell vanilla bilaterally
32
Breath
No odor
33
Lips
moist, no cracks
34
Oral Cavity Mucous Membranes
moist, intact
35
Gums
Pink, no bleeding
36
Teeth
good dentition
37
Palates and uvula
hard and soft palates no lesions; cranial nerves 9 and 10 intact
38
Tonsillar areas
1+ bilaterally
39
Oropharynx
mucous membranes moist and pink
40
Tongue
cranial nerve 12 intact; good ROM; pink
41
Oral cavity floor
no masses or lesions
42
Voice
good quality
43
Neck general structure
symmetrical
44
Trachea
midline
45
Thyroid
non palpable
46
Neck lymph nodes
not palpable
47
Neck muscles
Able to shrug shoulders against resistance; cranial nerve 11 intact
48
Cervical spine, ROM
Full ROM
49
Breast general structure
right and left symmetrical
50
Areola
symmetrical
51
Nipple
no deviation
52
Axilla
no nodes
53
Chest inspection and palpation
Symmetrical; no masses or lesions
54
Chest shape and appearance
Symmetric; no barrel chest
55
Type of respiration and rate
CTAB (clear to auscultation bilaterally); 80
56
Chest expansion
symmetric
57
Fremitus
palpable symmetrically
58
Chest Percussion
Resonance throughout
59
Resonance
Throughout symmetrically
60
Diaphragmatic Excursion
3-4
61
Chest Auscultation
CTAB
62
Breath Sounds
Pitch: high Intensity: Loud Quality: harsh, hollow, tubular Duration: inspiration < expiration
63
Cardiovascular Rate and Rhythm
RRR
64
PMI
no thrills
65
Cardiac Sounds
S1 - heard S2 - heard S3 - none S4 - none
66
Extra Sounds
no
67
Murmur
no
68
Carotids
2+ bilaterally
69
Jugular Venous Pulse and Pressure
DNA
70
Description of Peripheral Pulses
2+ bilaterally
71
Abdomen Contour and Tone
Flat
72
Abd Scars, Lesions
None
73
Liver
Non palpable
74
Spleen
Non palpable
75
Kidneys
Non palpable
76
Bladder
No distention
77
Hernias
None
78
Abd Masses
None
79
Abd Tenderness
None
80
Abd Percussion Sounds
Tympany
81
Vulva
No masses or lesions
82
Batholin's gland-urethra and skenes
No masses or lesions
83
Vagina
Pink, moist
84
Cervix
Pink, nulliparous
85
Uterus
Non tender
86
Adnexa
Non tender
87
Pelvic musculature
Good
88
Rectal external structure
No masses or lesions
89
Sphincter Tone
Good
90
Rectal Masses
None
91
Prostate
N/A
92
Stool
brown
93
Extremities general appearance
symmetrical
94
Gait
smooth, steady
95
Joints
no crepitus, full ROM
96
Epitrochlear nodes
none noted
97
Extremities ROM
full ROM bilaterally
98
Muscle strength
5/5 bilaterally
99
Muscle Mass
even
100
Spine contour
straight, midline
101
Spinal ROM
full
102
Vertebral Joints
no crepitus
103
CVA Tenderness
None
104
Mental Status
alert, oriented
105
Language
English
106
Cranial Nerves
1-12 intact
107
Motor Coordination (Upper and Lower)
Smooth bilaterally
108
Involuntary Movements
none
109
Romberg
Negative
110
DTR's
2+
111
Light touch
able to feel dull
112
Pain
able to feel sharp
113
Vibration
DNA
114
Position
Rapid alternating

Physical Examination Charting (1 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions