The Physical Exam: Terms and Findings Flashcards by Az-zahra Leon-Guerrero

General Appearance

drowsy or sleepy disposition

Somnolent

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General Appearance

physically wasting (extremely thin)

Cachectic/Emaciated

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General Appearance

Large body mass index (BMI)

Morbidly Obese

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General Appearance

Well-appearing patient in minimal distress

(Often used to describe well-appearing pediatric patients)

Nontoxic Appearing

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Head

normal appearance and size of the head

Normocephalic

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Head

no signs of trauma present

Atraumatic

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Skin

Bluish discoloration of the skin due to a lack of oxygen

Cyanosis

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Skin

An unhealthy paleness of the skin

Pallor

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Skin

Superficial reddening of the skin

Erythema

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Skin

Yellowing of skin due to abnormal bilirubin build-up

Jaundice

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Skin

Superficial wound to the top most layer of the skin

Abrasion

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Skin

A region of skin in which blood capillaries are ruptured

(AKA bruise)

Contusion

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Skin

An area of ruptured blood vessels similar to a contusion

(AKA bruise)

Ecchymosis

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Skin

A cut in the the skin

Laceration

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Skin

A small hole in the skin

Puncture

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Skin

round, localized area of edema on the skin

Wheal

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Skin

(a reaction) rash or hives

(irregular, blanch raised areas with redness)

Wheal-and-Flare

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Skin

hives or wheals which are either redder or paler than the surrounding area and are often accompanied by itching

Urticaria

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Skin

rash or hives

(flat red area covered with small confluent bumps)

Maculopapular

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Skin

small collection of pus under the skin

Pustules

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Skin

Fluid-filled blisters

Bullae

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Skin

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

Petechiae

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Skin

purple spots or blotches

(don’t turn white when pressed)

Purpura

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Skin

A hardened area of normally soft tissue

Induration

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# 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)

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.