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Vituity Scribe > The Physical Exam > Flashcards

The Physical Exam Flashcards

1
Q

somnolent

A

general; drowsy or sleepy disposition

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2
Q

cachectic/emaciated

A

general; physically wasting (extremely thin)

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3
Q

morbidly obese

A

general; large body mass index (BMI)

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4
Q

nontoxic appearing

A

general; well-appearing patient in minimal distress (often used for pediatric patients)

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5
Q

normocephalic

A

head; normal appearance and size of head

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6
Q

atraumatic

A

head; no signs of trauma present

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7
Q

cyanosis*

A

skin; bluish discoloration of the skin due to lack of oxygen

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8
Q

pallor

A

skin; an unhealthy paleness of the skin

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9
Q

erythema

A

skin; superficial reddening of the skin

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10
Q

jaundice

A

skin; yellowing of the skin due to abnormal bilirubin build-up

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11
Q

abrasion

A

skin; superficial wound to the top most layer of the skin

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12
Q

contusion

A

skin; a region of the skin in which blood capillaries are ruptures, aka bruise

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13
Q

ecchymosis

A

skin; an area of ruptured blood vessels similar to a contusion; aka a bruise

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14
Q

laceration*

A

skin; a cut in the skin

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15
Q

puncture

A

skin; 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

skin; a reaction of rash or hives (irregular, blanch raised areas with redness)

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18
Q

urticaria

A

skin; 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

skin; rash or hives (flat red area covered with small confluent bumps)

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20
Q

pustules

A

skin; small collection of pus under the skin

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21
Q

bullae

A

skin; fluid-filled blisters

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22
Q

petechiae

A

skin; 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

skin; purple spots or blotches (don’t turn white when pressed)

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24
Q

induration

A

skin; a hardened area of normally soft tissue

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25
Q

fluctuance

A

skin; movable and compressible

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26
Q

hemangioma

A

skin; a benign tumor consisting of blood vessels

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27
Q

cornea

A

eyes; 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

eyes; dense fibrous opaque outer coat enclosing the eyeball, except the part covered by cornea

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29
Q

conjunctiva

A

eyes; white area of the eyes

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30
Q

icterus

A

eyes; yellowing of sclera due to bilirubin build-up (often seen with jaundice)

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31
Q

subconjunctival hemorrhage

A

eyes; bright red patches in the conjunctiva of eyes due to ruptured blood vessels

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32
Q

extraocular movements intacts (EOMI)

A

eyes; 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

eyes: normal evaluation of the size, shape of the pupils and their reaction to light

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34
Q

papilledema

A

eyes; swelling of the optic disk due to an increase in intracranial pressure

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35
Q

fundi sharp

A

eyes; non-swollen optic nerve on exam of fundus (back of eye) with opthalmoscope

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36
Q

visual acuity

A

eyes; acuteness/sharpness of vision as measured by the eye chart

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37
Q

eyelid eversion

A

eyes; flipping of the eyelid for exam underneath eyelid

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38
Q

normal palpebral conjunctiva

A

eye membrane is clear

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39
Q

exophthalmos

A

eyes; eyes bulging out of socket

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40
Q

nystagmus

A

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

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41
Q

erythema of the external canal

A

ears; redness of the outer ear canal

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42
Q

cerumen impaction

A

ears; excessive earwax

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43
Q

tympanic membrane (TM)

A

ears; eardrum

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44
Q

erythematous TM

A

ears; red color of the TM

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45
Q

bulging TM

A

ears; protruding/outward curvature of the TM

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46
Q

retracted TM

A

ears; inward curve of the TM

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47
Q

poor light reflect

A

ears; 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

hemotypanum

A

ears; blood on the TM

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50
Q

mastoid tenderness

A

ears; tenderness over mastoid bone (located posterior to ear)

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51
Q

clear rhinorrhea

A

nose; clear nasal drainage

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52
Q

septal deviation

A

nose; displacement of nasal septum

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53
Q

septal hematoma

A

nose; bruising or bleeding in the nasal septum

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54
Q

dry mucous membranes

A

mouth; dry mouth

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55
Q

tongue laceration

A

mouth; cut on the tongue

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56
Q

no signs of oral trauma

A

mouth; no cuts/chipped teeth, etc

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57
Q

dental caries

A

mouth; cavity

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58
Q

poor dentition

A

mouth; bad teeth

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59
Q

pericoronitis

A

mouth; infection of the gums

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60
Q

parotid mass

A

mouth; enlargement of the parotid gland

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61
Q

trismus

A

mouth; inability to open mouth normally due to spasm of the jaw muscles

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62
Q

normal jaw approximation

A

mouth; normal jaw alignment

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63
Q

malocclusion

A

mouth; misalignment of the teeth when mouth closed

64
Q

uvula midline

A

throat; no deviation of the uvula to one side or another

65
Q

pharyngeal erythema

A

throat; redness of the throat

66
Q

pharyngeal exudate

A

throat; pus seen on the posterior throat

67
Q

peritonsilar abscess

A

throat; deep abscess adjacent to infected tonsils (collection of pus/swelling which is usually only visible if drained)

68
Q

carotid bruit

A

neck; abnormal flow of blood through the carotid artery

69
Q

jugular vein distension (JVD)

A

neck; swelling of the jugular vein (usually seen in heart failure patients)

70
Q

cervical vertebral tenderness

A

neck; pain along the cervical spine

71
Q

no step offs or crepitus

A

neck; 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

neck; no deviation of trachea from its usual location

74
Q

meningismus

A

neck; patient has stiff neck, photophobia, and headache which may suggest meningitis

75
Q

nuchal rigidity

A

neck; neck stiffness with neck movement

76
Q

bradycardia*

A

heart; slow heart rate; less than 60 bpm

77
Q

tachycardia*

A

heart; fast heart rate; faster than 100 bpm

78
Q

murmur

A

heart; an abnormal sound heard when listening to the heart

79
Q

systolic murmur

A

heart; heart murmur heard during systole (active pumping)

80
Q

diastolic murmur

A

heart; heart murmur heard during diastole (rest/active filling)

81
Q

distant heart sounds

A

heart; faint-sounding heart beat

82
Q

rubs

A

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

83
Q

gallops

A

heart; extra/abnormal heart sounds (should only hear 2 distinct sounds, but your hear 3 or 4 sounds)

84
Q

bradypnea

A

respiratory; abnormally slow breathing

85
Q

tachypnea

A

respiratory; abnormally rapid breathing

86
Q

apnea*

A

respiratory; temporary absence or cessation of breathing

87
Q

prolonged inspiratory expiratory phase

A

respiratory; increased time between inspiratory and expiratory phases

88
Q

rales

A

respiratory; wet, crackling sound with respirations (aka crackles)

89
Q

rhonchi

A

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

90
Q

wheezes

A

respiratory; difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways

91
Q

stridor

A

respiratory; harsh or high-pitched respiratory sound, caused by an obstruction of the air passages

92
Q

intercostal retractions

A

respiratory; use of intercostal muscles with breathing (indicated severe respiratory distress/work of breathing) - sunken intercostal muscles (can see ribs)

93
Q

accessory muscle use

A

respiratory; using extra muscles to breath (you can usually see an emphasis on use of diaphragm and intercostal muscle)

94
Q

costovertebral angle tenderness (CVAT)

A

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

95
Q

paraspinal muscle tenderness

A

back; tenderness in muscles adjacent to spine

96
Q

midline tenderness

A

back; tenderness directly over spine

97
Q

no step offs

A

back; no misalignment of thoracic/lumbar spine

98
Q

straight leg raise

A

back; if pain, indicative of herniated disk

99
Q

saddle anesthesia

A

back; loss of sensation around buttocks area

100
Q

distention

A

abdomen; bloating

101
Q

gravid*

A

abdomen; pregnant

102
Q

ascites

A

abdomen; accumulation of fluid in the peritoneal cavity

103
Q

tympanitic

A

abdomen; sound generated by examiner tapping his/her finger in contact with they belly distended due to extra gas/air in the large or small bowel

104
Q

organomegaly

A

abdomen; enlarged organ

105
Q

hepatomegaly

A

abdomen; enlarged liver

106
Q

splenomegaly

A

abdomen; enlarged spleen

107
Q

murphy’s sign

A

abdomen; pain the the RUQ that may indicate gallbladder infection

108
Q

rovsing’s sign

A

abdomen; palpation of the LLQ causes RLQ pain that may indicate appendicitis

109
Q

psoas sign

A

abdomen; pain produced with bending of the patient’s knees to chest that may indicate appendicitis

110
Q

heel tap test

A

abdomen; tap the heel to see if it causes pain, also done by having the patient jump to see of the pain is felt in the abdomen, indicates appendicitis

111
Q

mcburney’s point tenderness

A

abdomen; tenderness to palpitation in the mid-point of the RLQ which can indicate appendicitis

112
Q

umbilical hernia

A

abdomen; outward protrusion of the intra-abdominal tissue and.or bowel through belly button

113
Q

grey turner’s sign

A

abdomen; bruising in flank area (lower back area)

114
Q

cullen’s sign

A

abdomen; bruising in the skin around the umbilicus

115
Q

inguinal hernia

A

genital; protrusion in the groin

116
Q

cremasteric reflex

A

genital; upward pull of testicles and scrotum due to touch

117
Q

paraphymosis

A

genital; inability to pull back the foreskin back over the glans penis to its normal position

118
Q

guaiac (hemoccult) positive/negative

A

rectal; blood present/absent in stool

119
Q

rectal tone

A

rectal; tone of rectal muscles during digital exam

120
Q

melena*

A

rectal; dark tarry-like stool containing blood

121
Q

cervical motion tenderness (CMT)

A

pelvic; pain with movement of cervix

122
Q

adnexal tenderness

A

pelvic; tenderness in location of the ovaries and fallopian tubes

123
Q

os open/closed

A

pelvic; cervical os is open or closed

124
Q

vaginal vault

A

pelvic; vaginal cancal

125
Q

POC

A

pelvic; product of conception (fetus, placenta, etc)

126
Q

clubbing

A

extremities; deformity of finger/fingernails due to chronic cyanosis

127
Q

snuff box tenderness

A

extremities; pain in certain area of the wrist indicating a possible scaphoid bone fracture

128
Q

median/ulnar/radial sensory function

A

extremities; all these nerves run in the forearm, tested in the hand exam

129
Q

pain out of proportion

A

extremities; excessive pain not matching the expected with pressure applied by the doctor

130
Q

valgus/varus stress test

A

extremities; evaluation for knee instability

131
Q

homan’s sign

A

extremities; pain in calf or popliteal region

132
Q

pitting edema

A

extremities; persistent indentation of an area of skin when pressed on by the provider due to excessive edema

133
Q

aka/bka

A

extremities; above/below knee amputation

134
Q

ligamentous laxity

A

extremities; loose ligaments

135
Q

mcmurray’s test

A

extremities; rotation of the knee causes pain

136
Q

lachman’s test

A

extremities; pivot shift test causes pain

137
Q

bursa

A

extremities; small fluid filled sack surrounding a joint

138
Q

aphasia

A

neuro; loss of ability to express or understand speech

139
Q

dysphasia

A

neuro; having a difficult time finding what words to say

140
Q

dysarthria

A

neuro; difficult time communicating or articulation (slurred speech)

141
Q

purposeful movements

A

neuro; patient moves upon painful stimulation

142
Q

glasgow coma scale (gcs)

A

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

143
Q

localizes to pain

A

neuro; withdraws extremity where painful stimulation is applied

144
Q

grip strength

A

neuro; tested usually by patient gripping HCP’s fingers

145
Q

pronator drip

A

neuro; holds palms out upwards and look for movement of palms (rotation)

146
Q

dysmetria

A

neuro; finger to nose exam

147
Q

dysdiadochokinesia

A

neuro; inability to perform rapid alternating movements

148
Q

ataxic gait

A

neuro; walking abnormally and/or unsteadily

149
Q

heel to shin test

A

neuro; test for coordination

150
Q

romberg’s test

A

neuro; patient stands up with feet together and arms out to see if they can balance

151
Q

heel toe gait

A

neuro; tests the stability of a patient’s leg gait

152
Q

babinski sign

A

neuro; a reflex when swiping the sole of the foot to see if the big toe flexes up

153
Q

reflexes

A

neuro; involuntary/instantaneous movement

154
Q

affect

A

psych; observed emotional state of a person

155
Q

orientation

A

psych; orientation to person, place, time, and event ( AxOx4)

156
Q

hallucinations

A

psych; an experience involving the apparent perception of something not present

157
Q

suicidal/homicidal ideation

A

psych; thoughts of suicide or thoughts of homicide

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