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Scribe Training > Physical Exams > Flashcards

Physical Exams Flashcards

0
Q

What are some things that can be found using an external PE?

A
  1. General: No acute distress, well developed & well nourished.
  2. Eyes: PERRL
  3. ENT: moist mucosa
  4. Neck: supple
  5. Respiratory: no respiratory distress
  6. Skin: warm and dry
  7. Neuro: alert and oriented
  8. Psych: normal affect
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1
Q

What are the 11 body systems reviewed in a PE?

A
  1. General/constitutional
  2. Eyes
  3. ENT
  4. Neck
  5. Cardiovascular
  6. Respiratory
  7. Abdominal
  8. Extremities
  9. Skin
  10. Neurological
  11. Psychiatric
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2
Q

What are normal cardiac findings in a PE?

A

RRR, no murmurs, rubs, or gallops. Distal pulses intact.

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3
Q

What are normal findings when auscultating the lungs?

A

Clear to auscultation bilaterally, no wheezes, rales, or ronchi.

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4
Q

What are normal findings when palpating the abdomen?

A

Soft, non tender. Non distended. No guardig, rebound, or rigidity.

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5
Q

What are normal findings when examining the legs?

A

No edema, distal pulses intact.

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6
Q

What is a physician looking for when he…examines the throat?

A

Pharyngeal erythema or exudates

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7
Q

What is a physician looking for when he…examines the inner ear?

A

TM erythema or bulging

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8
Q

What is a physician looking for when he…auscultates the abdomen?

A

Hyper/hypo active bowel sounds

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9
Q

What is a physician looking for when he…touches the wrists?

A

Radial pulses

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10
Q

What is a physician looking for when he…squeezes the calves?

A

Calf tenderness

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11
Q

What is a physician looking for when he…pounds on the back?

A

CVA tenderness

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12
Q

In a general/constitutional exam, what is the opposite/abnormal finding of NAD?

A

Mild/moderate/severe distress (due to pain)

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13
Q

In a general/constitutional exam, what is the opposite/abnormal finding of well developed and well nourished?

A

Cachetic/emaciated/malnourished

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14
Q

In a general/constitutional exam, what is the opposite/abnormal finding of alert?

A

Somnolent, obtunded (blocked airway and unresponsive), unresponsive

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15
Q

In a PE of the head, what is the abnormal finding of AT/NC?

A

Any signs of trauma, sinus tenderness, angioedema

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16
Q

In a PE of the eyes, what is the abnormal finding of PERRL?

A

Anisocoria (unequal pupils)

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17
Q

In a PE of the eyes, what is the abnormal finding of EOMI?

A

EOM entrapment

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18
Q

In a PE of the eyes, what is the abnormal finding of sclera are anicteric?

A

Scleral icterus (yellow eyes)

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19
Q

In a PE of the eyes, what is the abnormal finding of normal conjunctiva?

A

Pale conjunctiva, conjunctival infection (red and blood shot)

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20
Q

In a PE of the eyes, what is the abnormal finding of clear anterior chamber?

A

Hyphema (blood in anterior chamber of eye)

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21
Q

In a PE of the eyes, what is the abnormal finding of sharp disc margins?

A

Papilledema (optic disc swelling)

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22
Q

In a PE of the eyes, what is the abnormal finding of normal cornea?

A

Corneal abrasion/ulcerations, fluorescein uptake, or foreign body

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23
Q

What instrument is used in a fundoscopic internal eye exam?

A

Opthalmascope

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24
Q

What instrument is used in a PE of the external eye?

A

Woods lamp or fluorescein

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25
Q

What instrument is used in a PE of the ears?

A

Otoscope

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26
Q

In a PE of the ears, What is the abnormal finding of a normal TM?

A

TM erythema, TM bulging, TM dullness, TM obscured by cerumen (ear wax)

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27
Q

In a PE of the nose, what is the abnormal finding of normal nares (nostrils)

A

Epistaxes, rhinorrhea, boggy turbinates (swollen inner nose), septal hematoma

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28
Q

In a PE of the mouth/throat, what is the abnormal finding of moist mucous membranes?

A

Dry mucous membranes (DMM)

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29
Q

In a PE of the mouth/throat, what is the abnormal finding of oropharynx (OP) normal?

A

Pharyngeal erythema, tonsillar exudate, tonsillar hypertrophy, peritonsillar abscess (PTA)

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30
Q

In a PE of the mouth/throat, what is the abnormal finding of normal dentition?

A

Edentulous (missing teeth), dental caries (cavities)

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31
Q

In a PE of the neck, what is the abnormal finding of supple?

A

Nuchal rigidity, meningismus, limited ROM, JVD, carotid bruit, cervical lymphadenopathy (swollen lymph), thyromegaly, vertebral point vs para spinal tenderness

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32
Q

In a PE of the cardiovascular, what is the abnormal finding of a regular rate?

A

Tachycardia (>100 bpm) or bradycardia (<60 bpm)

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33
Q

In a PE of the cardiovascular, what is the abnormal finding of a regular rhythm?

A

Irregular irregular rhythm

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34
Q

In a PE of the cardiovascular, what is the abnormal finding of heart sounds normal?

A

Murmurs, rubs, or gallops, or extrasystoles (extra beats)

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35
Q

In a PE of the perfusion rates, what is the abnormal finding of pulses equal and symmetric?

A

Unequal pulses

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36
Q

In a PE of the perfusion rates, what is the abnormal finding of capillary refill <2 sec?

A

Delayed capillary refill

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37
Q

What is the pulse grading scale?

A 
0 absent
1+ barely palpable 
2+ easily palpable
3+ full
4+ bounding/aneurysmal
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38
Q

In a PE of the pulmonary, what is the abnormal finding of no respiratory distress?

A

Mild/moderate/severe respiratory distress

39
Q

In a PE of the pulmonary, what is the abnormal finding of normal respiratory rate?

40
Q

In a PE of the pulmonary, what is the abnormal finding of normal effort?

A

Accessory muscle use

41
Q

In a PE of the pulmonary, what is the abnormal finding of breath sounds clear and equal?

A

Wheezes (inspiratory or expiratory) rales, ronchi

42
Q

In a PE of the abdomen, what is the abnormal finding of soft?

A

Rigid (involuntary guarding)

43
Q

In a PE of the abdomen, what is the abnormal finding of non tender?

A

Mild/mod/severe tenderness, voluntary guarding

44
Q

In a PE of the abdomen, what is the abnormal finding of no peritoneal signs?

A

Rebound tenderness, rigidity

45
Q

In a PE of the abdomen, what is the abnormal finding of normal bowel sounds ?

A

Absent/hypo/hyper active bowel sounds

46
Q

In a PE of the abdomen, what is the abnormal finding of non distended?

47
Q

What is Murphy’s sign?

A

Palpating abd for gall bladder tenderness in RUQ

48
Q

What is positive mc burneys pt?

A

2/3 of way b/t superior iliac crest and epigastrium

49
Q

What is positive obturators sign?

A

Knee to chest

50
Q

What is positive rovsings sign?

A

Palpate LLQ that causes inc. pain in RLQ

51
Q

What are the 4 signs for appendicitis?

A
  1. Mc burneys point
  2. Positive psoas sign
  3. Positive obturators sign
  4. Positive rovsings sign
52
Q

A normal rectal exam is…

A

Heme negative (guaiac)

53
Q

What is a rectal prolapse?

A

Rectum protruding from anus

54
Q

What does it mean when something is thrombosed?

A

Actively bleeding

55
Q

What is. Decreased rectal tone indicative of?

A

Spinal cord injury

56
Q

What is important to document during a male or female genital exam?

A

Female/male chaperone present

57
Q

Adnexal tenderness or mass is an abnormal finding for what female genital exam?

A

Normal external genitalia?

58
Q

Cervical motion tenderness, uterine tenderness is an abnormal finding for what?

A

Normal bimanual exam

59
Q

Abnormal findings in a genital exam are?

A
  1. Testicular tenderness
  2. Epididymal tenderness
  3. Testicular edema
  4. Testicular mass
  5. Urethral discharge
  6. Inguinal hernia
60
Q

What is a normal MS finding?

A

FROM, non tender

61
Q

What does distal CSMT stand for?

A

Circulation, sensory, motor, tendon

62
Q

What is abnormal FROM?

A

Decreased ROM 2 degrees, pain

63
Q

What is pitting pedal Edema and how is it measured?

A

When palpating leaves a “pit” in the skin. Measured from trace to 4+

64
Q

What are palpable cords/homans sign indicative of?

65
Q

What is homans sign?

A

Pain in calves when pointing toes

66
Q

Para spinal tenderness is indicative of what?

A

Muscular injury

67
Q

Vertebral point tenderness is indicative of what?

A

Spinal injury

68
Q

CVA tenderness is indicative of what?

A

Pyelonephritis

69
Q

Midline deformities/ step offs are indicative of what?

A

Spinal Injury/trauma

70
Q

Cyanotic skin is

A

Blue (hypoxia)

71
Q

Urticaria are

72
Q

Petechiae/purpura is

A

A dangerous rash

73
Q

Calor

A

Increased warmth

74
Q

Induration is indicative of…

A

Cellulitis

75
Q

Fluctuance comes from

A

An abscess

76
Q

Lymphangitis

A

Streaking visible infection

77
Q

Avulsion

A

Similar to skin tear but no longer there (older PT)

78
Q

Normal neuro is

A

A&O x4 (person, place, time, event)

79
Q

What do you document when deep tendon reflexes are normal?

A

DTR 2+ and equal

80
Q

What do you document when all cranial nerves intact?

A

CN II-XII intact

81
Q

What do you document with normal walking?

82
Q

What do u document when motor strength is normal?

A

Motor strength 5/5 and symmetric

83
Q

Dysarthria

A

Difficulty speaking

84
Q

Hypoesthesia

A

Decreased sensation

85
Q

How do you measure Motor strength?

A

0/5-5/5 (flaccid to normal)

86
Q

What is a positive babinski?

A

Toes fan out and up (normal is fanning down)

87
Q

What is positive Romberg?

A

PT stands and closes eyes and sees if off balance

88
Q

Vertical nystagmus

A

Eyes shake

89
Q

What are 2 abnormal psych findings for normal speech?

A

Tangential and pressured speech

90
Q

Battles sign is indicative of what kind of trauma?

A

Bleeding behind ears…head trauma

91
Q

If the physician notes bruising across the abdomen after an MVA, what will he verbalize to you?

A

Positive seatbelt sign

92
Q

Why is it important to note “crying with tears” in a pediatric exam?

A

It indicates hydration

93
Q

MAE X4 means what in a pediatric exam?

A

Moves all 4 extremities

94
Q

What is the most important thing to know when examining an abnormal pediatric pt?

A

Never document an abnormal finding unless the physician tells you to do so.

95
Q

Why is it important to document no scleral icterus in an abdominal exam?

A

It rules out liver failure

96
Q

FNF

A

Normal finger-nose-finger

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