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CEP America Scribe Terms > The Physical Exam > Flashcards

The Physical Exam Flashcards

1
Q

Somnolent

A

Drowsy or sleepy disposition

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2
Q

Cachectic/Emaciated

A

Physically wasting (extremely thin)

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3
Q

Morbidly Obese

A

Large body mass index (BMI)

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4
Q

Nontoxic Appearing

A

Well-appearing patient in minimal distress

Often used to describe well-appearing pediatric patients

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5
Q

Normocephalic

A

Normal appearance and size of the head

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6
Q

Atraumatic (Head)

A

No signs of trauma present

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7
Q

**Cyanosis

A

Bluish discoloration of the skin due to a lack of oxygen

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8
Q

Pallor

A

An unhealthy paleness of the skin

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9
Q

Erythema

A

Superficial reddening of the skin

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10
Q

Jaundice

A

Yellowing of skin due to abnormal bilirubin build-up

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11
Q

Abrasion

A

Superficial wound to the top most layer of the skin

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12
Q

Contusion

A

A region of skin in which blood capillaries are ruptured; AKA bruise

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13
Q

Ecchymosis

A

An area of ruptured blood vessels similar to a contusion; AKA bruise

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14
Q

**Laceration

A

A cut in the the skin

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15
Q

Puncture

A

A small hole in the skin

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16
Q

Wheal

A

Round, localized area of edema on the skin

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17
Q

Wheal-and-Flare

A

(A reaction) rash or hives (irregular, blanch raised areas with redness)

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18
Q

Urticaria

A

Hives or wheals which are either redder or paler than the

surrounding area and are often accompanied by itching

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19
Q

Maculopapular

A

Rash or hives (flat red area covered with small confluent bumps)

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20
Q

Pustules

A

Small collection of pus under the skin

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21
Q

Bullae

A

Fluid-filled blisters

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22
Q

Petechiae

A

A small round flat dark-red spot caused by bleeding into the skin or beneath the mucus membrane

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23
Q

Purpura

A

Purple spots or blotches (don’t turn white when pressed)

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24
Q

Induration

A

A hardened area of normally soft tissue

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25
Q

Fluctuance

A

Movable and compressible

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26
Q

Hemangioma

A

A benign tumor consisting of blood vessels

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27
Q

Cornea

A

The transparent coat of the eyeball that covers the iris and pupil; lets light into the eye

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28
Q

Sclera

A

The dense fibrous opaque outer coat enclosing the eyeball - except the part covered by the cornea

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29
Q

Conjunctiva

A

White area of the eyes

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30
Q

Icterus

A

Yellowing of sclera due to bilirubin build-up (often seen with jaundice)

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31
Q

Subconjunctival Hemorrhage

A

Bright red patches in conjunctiva of eyes due to ruptured blood vessels

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32
Q

Extraocular Movements

Intact (EOMI)

A

Appropriate function of the extraocular muscles, tested with “follow my finger”

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33
Q

Pupils equal, round and reactive to light (PERRL)

A

Normal evaluation of the size, shape of the pupils and their reaction to light

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34
Q

Papilledema

A

Swelling of the optic disk due to an increase in intracranial pressure

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35
Q

Fundi Sharp

A

Non-swollen optic nerve on exam of fundus (back of eye) with ophthalmoscope

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36
Q

Visual Acuity

A

Acuteness / sharpness of vision as measured by the eye chart

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37
Q

Eyelid Eversion

A

Flipping the eyelid for exam underneath the eyelid

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38
Q

Normal Palpebral Conjunctiva

A

Eyelid membrane is clear

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39
Q

Exophthalmos

A

Bulging of eyes out of socket

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40
Q

Nystagmus

A

involuntary rapid eye movements – often reported as horizontal, vertical, or rotary

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41
Q

Erythema of the External Canal

A

Redness of outer ear canal

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42
Q

Cerumen Impaction

A

Excessive earwax

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43
Q

Tympanic Membrane (TM)

A

Eardrum

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44
Q

Erythematous TM

A

Red color of the TM

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45
Q

Bulging TM

A

Protruding / outward curvature of the TM

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46
Q

Retracted TM

A

Inward curve of the TM

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47
Q

Poor Light Reflect

A

Cone of light does not reflect on TM

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48
Q

Unable to Visualize Landmarks

A

Provider cannot see landmarks behind TM

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49
Q

Hemotympanum

A

Blood on the TM

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50
Q

Mastoid Tenderness

A

Tenderness over mastoid bone (located posterior to ear)

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51
Q

Clear Rhinorrhea

A

Clear nasal drainage

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52
Q

Septal Deviation

A

Displacement of nasal septum

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53
Q

Septal Hematoma

A

Bruising or bleeding in the nasal septum

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54
Q

Dry Mucous Membranes

A

Dry mouth

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55
Q

Tongue Laceration

A

Cut on the tongue

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56
Q

No Signs of Oral Trauma

A

No cuts/chipped teeth/etc

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57
Q

Dental Caries

A

Cavity

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58
Q

Poor Dentition

A

Bad teeth

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59
Q

Pericoronitis

A

Infection of the gums

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60
Q

Parotid Mass

A

Enlargement of the parotid gland

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61
Q

Trismus

A

Inability to open mouth normally due to spasm of the jaw muscles

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62
Q

Normal Jaw Approximation

A

Normal jaw alignment

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63
Q

Malocclusion

A

Misalignment of the teeth when mouth closed

64
Q

Uvula Midline

A

No deviation of the uvula to one side or another

65
Q

Pharyngeal Erythema

A

Redness of the throat

66
Q

Pharyngeal Exudate

A

Pus seen on the posterior throat

67
Q

Peritonsilar Abscess

A

Deep abscess adjacent to infected tonsils (collection of

pus/swelling which is usually only visible if drained)

68
Q

Carotid Bruit

A

Abnormal flow of blood through the carotid artery

69
Q

Jugular Vein Distension (JVD)

A

Swelling of the jugular vein (usually seen in heart failure

patients)

70
Q

Cervical Vertebral Tenderness

A

Pain along cervical spine

71
Q

No Step-offs or crepitus

A

No misalignment of the vertebral bodies (spinous processes) as the spine is palpated

72
Q

Anterior Cervical Lymphadenopathy

A

Swollen lymph nodes under jaw and along anterior neck area

73
Q

Trachea Midline

A

No deviation of trachea from its usual location

74
Q

Meningismus

A

Patient has neck stiffness, photophobia, and headache which may suggest meningitis

75
Q

Nuchal Rigidity

A

Neck stiffness with neck movement

76
Q

**Bradycardia

A

Slow heart rate; less than 60 beats per minute

77
Q

**Tachycardia

A

Fast heart rate; greater than 100 beats per minute

78
Q

Murmur

A

An abnormal sound heard when listening to the heart

79
Q

Systolic Murmur

A

Heart murmur heard during systole (active pumping)

80
Q

Diastolic Murmur

A

Heart murmur heard during diastole (rest/active filling)

81
Q

Distant Heart Sounds

A

Faint-sounding heart beat

82
Q

Rubs

A

Coarse sounds produced when the heart “rubs” on inflamed pericardium (heart tissue) during contractions

83
Q

Gallops

A

Extra/abnormal heart sounds (should only hear 2 distinct sounds, but you hear 3 or 4 sounds)

84
Q

Bradypnea

A

Abnormally slow breathing

85
Q

Tachypnea

A

Abnormally rapid breathing

86
Q

**Apnea

A

Temporary absence or cessation of breathing

87
Q

Prolonged Inspiratory Expiratory Phase

A

Increased time between inspiratory and expiratory phases

88
Q

Rales

A

Wet, crackling sound with respirations (aka crackles)

89
Q

Rhonchi

A

A whistling or snoring sound heard on auscultation of the chest when air channels are partially obstructed; plural of rhonchus

90
Q

Wheezes

A

Difficult breathing with a whistling sound resulting from

narrowing of the lumen of the respiratory passageways

91
Q

Stridor

A

Harsh or high-pitched respiratory sound, caused by an

obstruction of the air passages

92
Q

Intercostal Retractions

A

Use of intercostal muscles with breathing (indicates severe respiratory distress/work of breathing) – sunken intercostal muscles (can see ribs)

93
Q

Accessory Muscle Use

A

Using extra muscles to breath (you can usually see an emphasis on use of diaphragm and intercostal muscles)

94
Q

Costovertebral Angle Tenderness (CVAT)

A

Angle in back where kidneys are (HCP taps); left, right and bilateral – if pain then possible kidney pathology

95
Q

Paraspinal Muscle Tenderness

A

Tenderness in muscles adjacent to spine

96
Q

Midline Tenderness

A

Tenderness directly over spine

97
Q

No Step-offs

A

No misalignment of thoracic/lumbar spine

98
Q

Straight Leg Raise

A

If pain, indicative of herniated disk

99
Q

Saddle Anesthesia

A

Loss of sensation around buttocks area

100
Q

Distension

A

Bloating

101
Q

**Gravid

A

Pregnant

102
Q

Ascites

A

Accumulation of fluid in the peritoneal cavity

103
Q

Tympanitic

A

Sound generated by examiner tapping his/her finger in contact with the a belly distended due to extra gas/air in the large or small bowel

104
Q

Organomegaly

A

Enlarged organ

105
Q

Hepatomegaly

A

Enlarged liver

106
Q

Splenomegaly

A

Enlarged spleen

107
Q

Murphy’s Sign

A

Pain in right upper quadrant that may indicate gallbladder infection

108
Q

Rovsing’s Sign

A

Palpation of the left lower quadrant causes right lower quadrant pain that may indicate appendicitis

109
Q

Psoas Sign

A

Pain produced with bending of the patient’s knees to chest that may indicate appendicitis

110
Q

Heel Tap Test

A

Tap the heal to see if it causes pain, also done by having the patient jump up to see if pain is felt in the abdomen – may indicate appendicitis

111
Q

McBurney’s Point Tenderness

A

Tenderness to palpation in the mid-point of the right lower quadrant (RLQ) which can indicate appendicitis

112
Q

Umbilical Hernia

A

Outward protrusion of intra-abdominal tissue and/or bowel through belly button

113
Q

Grey Turner’s Sign

A

Bruising in flank area (lower back area)

114
Q

Cullen’s Sign

A

Bruising in the skin around the umbilicus

115
Q

Inguinal Hernia

A

Protrusion in the groin

116
Q

Cremasteric Reflex

A

Upward pull of testicles and scrotum due to touch

117
Q

Paraphymosis

A

Inability to pull back the foreskin back over the glans penis to its normal position

118
Q

Guaiac (Hemoccult) positive/negative

A

Blood present/absent in stool

119
Q

Rectal Tone

A

Tone of rectal muscles during digital exam

120
Q

**Melena

A

Dark, tarry like stool containing blood

121
Q

Cervical Motion Tenderness (CMT)

A

Pain with movement of cervix

122
Q

Adnexal Tenderness

A

Tenderness in location of the ovaries and fallopian tubes

123
Q

Os Open/Closed

A

Cervical os (opening to cervix) is open or closed

124
Q

Vaginal Vault

A

Vaginal canal

125
Q

POC

A

Product of conception (fetus, placenta, etc)

126
Q

Clubbing

A

Deformity of finger/fingernail due to chronic cyanosis

127
Q

Snuff Box Tenderness

A

Pain in certain area of the wrist indicating a possible scaphoid bone fracture

128
Q

Median/Ulnar/Radial Sensory Function

A

All these nerves run in forearm…tested in the hand exam

129
Q

Pain Out of Proportion

A

Excessive pain not matching the expected with pressure applied by the doctor

130
Q

Valgus/Varus Stress Test

A

Evaluation for knee instability

131
Q

Homan’s Sign

A

Pain in calf or popliteal region

132
Q

Pitting Edema

A

Persistent indention of an area of skin when pressed on by the provider due to excess edema

133
Q

AKA / BKA

A

Above / below knee amputation (Indicate R or L)

134
Q

Ligamentous Laxity

A

Loose ligaments

135
Q

McMurray’s Test

A

Rotation of knee causes pain

136
Q

Lachman’s Test

A

Pivot shift test causes pain

137
Q

Bursa

A

Small fluid filled sack surrounding a joint

138
Q

Aphasia

A

Loss of ability to express or understand speech

139
Q

Dysphasia

A

Having a difficult time finding what words to say

140
Q

Dysarthria

A

Difficult time communicating or articulation (i.e. slurred speech)

141
Q

Purposeful Movements

A

Patient moves upon painful stimulation

142
Q

Glasgow Coma Scale (GCS)

A

A scoring system used to describe the level of consciousness in a person following a traumatic brain injury

143
Q

Localizes to Pain

A

Withdraws extremity where painful stimulation is applied

144
Q

Grip Strength

A

Tested usually by patient gripping HCP’s fingers (L+R+Bi)

145
Q

Pronator Drift

A

Hold palms out upwards and look for movement of palms (rotation)

146
Q

Dysmetria

A

Finger to nose exam

147
Q

Dysdiadochokinesia

A

Inability to perform rapid alternating movements

148
Q

Ataxic

A

Gait walking abnormally and/or unsteadily

149
Q

Heel to Shin Test

A

Test for coordination

150
Q

Romberg’s Test

A

Patient stands up with feet together and arms out to see if they can balance

151
Q

Heel Toe Gait

A

Tests the stability of a patient’s gait

152
Q

Babinski Sign

A

A reflex - swipe sole of foot to see if big toe flexes up

153
Q

Reflexes

A

Involuntary/instantaneous movement

154
Q

Affect

A

The observed emotional state of a person

155
Q

Orientation

A

Orientation to person, place, time, and event (A/O x 4)

156
Q

Hallucinations (auditory or visual)

A

An experience involving the apparent perception of something not present

157
Q

Suicidal (SI) /Homicidal Ideation (HI)

A

Thoughts of suicide / thoughts of homicide

CEP America Scribe Terms (4 decks)

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