The Physical Exam: Terms and Findings Flashcards
These are common/standard findings of the Physical Exam of the body systems: General Appearance, Head, Skin, Eyes, Ears, Nose, Mouth, Throat, Neck, Chest Wall, Heart, Respiratory, Abdomen, Back, Pelvic, Genital, Rectal, Extremities, Neurologic, and Psychiatric.
General Appearance
drowsy or sleepy disposition
Somnolent
General Appearance
physically wasting (extremely thin)
Cachectic/Emaciated
General Appearance
Large body mass index (BMI)
Morbidly Obese
General Appearance
Well-appearing patient in minimal distress
(Often used to describe well-appearing pediatric patients)
Nontoxic Appearing
Head
normal appearance and size of the head
Normocephalic
Head
no signs of trauma present
Atraumatic
Skin
Bluish discoloration of the skin due to a lack of oxygen
Cyanosis
Skin
An unhealthy paleness of the skin
Pallor
Skin
Superficial reddening of the skin
Erythema
Skin
Yellowing of skin due to abnormal bilirubin build-up
Jaundice
Skin
Superficial wound to the top most layer of the skin
Abrasion
Skin
A region of skin in which blood capillaries are ruptured
(AKA bruise)
Contusion
Skin
An area of ruptured blood vessels similar to a contusion
(AKA bruise)
Ecchymosis
Skin
A cut in the the skin
Laceration
Skin
A small hole in the skin
Puncture
Skin
round, localized area of edema on the skin
Wheal
Skin
(a reaction) rash or hives
(irregular, blanch raised areas with redness)
Wheal-and-Flare
Skin
hives or wheals which are either redder or paler than the surrounding area and are often accompanied by itching
Urticaria
Skin
rash or hives
(flat red area covered with small confluent bumps)
Maculopapular
Skin
small collection of pus under the skin
Pustules
Skin
Fluid-filled blisters
Bullae
Skin
a small round flat dark-red spot caused by bleeding into the skin or beneath the mucus membrane
Petechiae
Skin
purple spots or blotches
(don’t turn white when pressed)
Purpura
Skin
A hardened area of normally soft tissue
Induration
Skin
Movable and compressible
Fluctuance
Skin
A benign tumor consisting of blood vessels
Hemangioma
Eyes
The transparent coat of the eyeball that covers the iris and pupil
(lets light into the eye)
Cornea
Eyes
The dense fibrous opaque outer coat enclosing the eyeball
(except the part covered by the cornea)
Sclera
Eyes
white area of the eyes
Conjunctiva
Eyes
Yellowing of sclera due to bilirubin build-up(often seen with jaundice)
Icterus
Eyes
Bright red patches in conjunctiva of eyes due to ruptured blood vessels
Subconjunctival Hemorrhage
Eyes
appropriate function of the extraocular muscles
(tested with “follow my finger”)
Extraocular Movements Intact (EOMI)
Eyes
normal evaluation of the size, shape of the pupils and their reaction to light
Pupils equal, round and reactive to light (PERRL)
Eyes
swelling of the optic disk due to an increase in intracranial pressure
Papilledema
Eyes
non-swollen optic nerve on exam of fundus (back of eye) with ophthalmoscope
Fundi Sharp
Eyes
acuteness / sharpness of vision as measured by the eye chart
Visual Acuity
Eyes
flipping the eyelid for exam underneath the eyelid
Eyelid Eversion
Eyes
eyelid membrane is clear
Normal Palpebral Conjunctiva
Eyes
bulging of eyes out of socket
Exophthalmos
Eyes
involuntary rapid eye movements – often reported as horizontal, vertical, or rotary.
Nystagmus
Ears
redness of outer ear canal
Erythema of the External Canal
Ears
excessive earwax
Cerumen Impaction
Ears
Eardrum
Tympanic Membrane (TM)
Ears
red color of the TM
Erythematous TM
Ears
protruding / outward curvature of the TM
Bulging
Ears
inward curve of the TM
Retracted TM
Ears
cone of light does not reflect on TM
Poor Light Reflect
Ears
Provider cannot see landmarks behind TM
Unable to Visualize Landmarks
Ears
Blood on the TM
Hemotympanum
Ears
Tenderness over mastoid bone (located posterior to ear)
Mastoid Tenderness
Nose
clear nasal drainage
Clear Rhinorrhea
Nose
displacement of nasal septum
Septal Deviation
Nose
bruising or bleeding in the nasal septum
Septal Hematoma
Mouth
dry mouth
Dry Mucous Membranes
Mouth
cut on the tongue
Tongue Laceration
Mouth
no cuts/chipped teeth/etc.
No Signs of Oral Trauma
Mouth
Cavity
Dental Caries
Mouth
bad teeth
Poor Dentition
Mouth
infection of the gums
Pericoronitis
Mouth
enlargement of the parotid gland
Parotid Mass
Mouth
inability to open mouth normally due to spasm of the jaw muscles
Trismus
Mouth
normal jaw alignment
Normal Jaw Approximation
Mouth
Malocclusion
misalignment of the teeth when mouth closed
Throat
no deviation of the uvula to one side or another
Uvula Midline
Throat
redness of the throat
Pharyngeal Erythema
Throat
pus seen on the posterior throat
Pharyngeal Exudate
Throat
deep abscess adjacent to infected tonsils
(collection of pus/swelling which is usually only visible if drained)
Peritonsillar Abscess
Neck
abnormal flow of blood through the carotid artery
Carotid Bruit
Neck
swelling of the jugular vein
(usually seen in heart failure patients)
Jugular Vein Distension (JVD)
Neck
pain along cervical spine
Cervical Vertebral Tenderness
Neck
no misalignment of the vertebral bodies (spinous processes) as the spine is palpated
No Step-offs or crepitus
Neck
swollen lymph nodes under jaw and along anterior neck area
Anterior Cervical Lymphadenopathy
Neck
no deviation of trachea from its usual location
Trachea Midline
Neck
patient has neck stiffness, photophobia, and headache which may suggest meningitis
Meningismus
Neck
neck stiffness with neck movement
Nuchal Rigidity
Chest Wall
gas or air present under the subcutaneous skin
Subcutaneous Emphysema
Chest Wall
crackling/popping sensation that a provider feels under the skin due to air being present in skin tissue
Crepitus
(also reported as “crepitance”)
Heart
Slow heart rate; less than 60 beats per minute
Bradycardia
Heart
Fast heart rate; greater than 100 beats per minute
Tachycardia
Heart
An abnormal sound heard when listening to the heart.
Murmur
Heart
Heart murmur heard during systole
(active pumping)
Systolic Murmur
Heart
Heart murmur heard during diastole
(rest/active filling)
Diastolic Murmur
Heart
Faint-sounding heartbeat
Distant Heart Sounds
Heart
Coarse sounds produced when the heart “rubs” on inflamed pericardium (heart tissue) during contractions
Rubs
Heart
extra/abnormal heart sounds
(should only hear 2 distinct sounds, but you hear 3 or 4 sounds)
Gallops
Respiratory
Abnormally slow breathing
Bradypnea
Respiratory
Abnormally rapid breathing
Tachypnea
Respiratory
temporary absence or cessation of breathing
Apnea
Respiratory
increased time between inspiratory and expiratory phases
Prolonged Inspiratory / Expiratory Phase
Respiratory
using extra muscles to breathe
(usually see an emphasis on use of diaphragm and intercostal muscles)
Accessory Muscle Use
Respiratory
wet, crackling sound with respirations
(aka crackles)
Rales
Respiratory
a whistling or snoring sound heard on auscultation of the chest when air channels are partially obstructed; plural of rhonchus
Rhonchi
Respiratory
difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways
Wheezes
Respiratory
harsh or high-pitched respiratory sound, caused by an obstruction of the air passages
Stridor
Respiratory
use of intercostal muscles with breathing (indicates severe respiratory distress/work of breathing) – sunken intercostal muscles (can see ribs)
Intercostal Retractions
Abdomen
bloating
Distension
Abdomen
pregnant
Gravid
Abdomen
accumulation of fluid in the peritoneal cavity
Ascites
Abdomen
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
Tympanitic
Abdomen
enlarged organ
Organomegaly
Abdomen
enlarged liver
Hepatomegaly
Abdomen
enlarged spleen
Splenomegaly
Abdomen
pain in right upper quadrant that may indicate gallbladder infection
Murphy’s Sign
Abdomen
palpation of the left lower quadrant causes right lower quadrant pain that may indicate appendicitis
Rovsing’s Sign
Abdomen
pain produced with bending of the patient’s knees to chest that may indicate appendicitis
Psoas Sign
Abdomen
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)
Heel Tap Test
Abdomen
tenderness to palpation in the mid-point of the right lower quadrant (RLQ) which can indicate appendicitis
McBurney’s Point Tenderness
Abdomen
outward protrusion of intra-abdominal tissue and/or bowel through belly button
Umbilical hernia
Abdomen
bruising in flank area (lower back area)
Grey Turner’s Sign
Abdomen
bruising in the skin around the umbilicus
Cullen’s Sign
Back
angle in back where kidneys are (HCP taps); left, right and bilateral
(if pain then possible kidney pathology)
Costovertebral Angle Tenderness (CVAT)
Back
tenderness in muscles adjacent to spine
Paraspinal Muscle Tenderness
Back
tenderness directly over spine
Midline Tenderness
Back
no misalignment of thoracic/lumbar spine
No Step-offs
Back
if pain, indicative of herniated disk
Straight Leg Raise
Back
loss of sensation around buttocks area
Saddle Anesthesia
Pelvic
pain with movement of cervix
Cervical Motion Tenderness (CMT)
Pelvic
tenderness in location of the ovaries and fallopian tubes
Adnexal tenderness
Pelvic
vaginal canal
Vaginal Vault
Pelvic
cervical os (opening to cervix) is open or closed
Os Open/Closed
Pelvic
product of conception (fetus, placenta, etc)
POC
Genital
protrusion in the groin
Inguinal Hernia
Genital
upward pull of testicles and scrotum due to touch
Cremasteric Reflex
Genital
inability to pull back foreskin back over glans penis to its normal position
Paraphimosis
Rectal
blood present/absent in stool
Guaiac (Hemoccult) positive/negative
Rectal
tone of rectal muscles during digital exam
Rectal Tone
Rectal
dark, tarry like stool containing blood
Melena
Extremities
deformity of finger/fingernail due to chronic cyanosis
Clubbing
Extremities
rotation of knee causes pain
McMurray’s Test
Extremities
pain in certain area of the wrist indicating a possible scaphoid bone fracture
Snuff Box Tenderness
Extremities
pivot shift test causes pain
Lachman’s Test
Extremities
all these nerves run in forearm…tested in the hand exam
Median/Ulnar/Radial Sensory Function
Extremities
excessive pain not matching the expected with pressure applied by the doctor
Pain Out of Proportion
Extremities
evaluation for knee instability
Valgus/Varus Stress Test
Extremities
pain in calf or popliteal region
Homan’s Sign
Extremities
persistent indention of an area of skin when pressed on by the provider due to excess edema
Pitting Edema
Extremities
above / below knee amputation
(Indicate R or L)
AKA / BKA
Extremities
loose ligaments
Ligamentous Laxity
Extremities
small fluid filled sack surrounding a joint
Bursa
Neurologic
Loss of ability to express or understand speech
Aphasia
Neurologic
having a difficult time finding what words to say
Dysphasia
Neurologic
difficult time communicating or articulation
(i.e. slurred speech)
Dysarthria
Neurologic
Patient moves upon painful stimulation
Purposeful Movements
Neurologic
A scoring system used to describe the level of consciousness in a person following a traumatic brain injury.
Glasgow Coma Scale (GCS)
Neurologic
withdraws extremity where painful stimulation is applied
Localizes to Pain
Neurologic
tested usually by patient gripping HCP’s fingers (L+R+Bi)
Grip Strength
Neurologic
hold palms out upwards and look for movement of palms
(rotation)
Pronator Drift
Neurologic
finger to nose exam
Dysmetria
Neurologic
inability to perform rapid alternating movements
Dysdiadochokinesia
Neurologic
walking abnormally and/or unsteadily
Ataxic Gait
Neurologic
test for coordination
Heel to Shin Test
Neurologic
patient stands up with feet together and arms out to see if they can balance
Romberg’s Test
Neurologic
tests the stability of a patient’s gait
Heel Toe Gait
Neurologic
a reflex - swipe sole of foot to see if big toe flexes up
Babinski Sign
Neurologic
involuntary/instantaneous movement
Reflexes
Psychiatric
the observed emotional state of a person
Affect
Psychiatric
orientation to person, place, time, and event
(A/O x 4)
Orientation
Psychiatric
an experience involving the apparent perception of something not present
Hallucinations (auditory or visual)
Psychiatric
thoughts of suicide / thoughts of homicide
Suicidal (SI) /Homicidal Ideation (HI)
