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Medical Scribe: Emergency Department > The Physical Exam: Terms and Findings > Flashcards

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.

You may prefer our related Brainscape-certified flashcards:
Royal College: Emergency Medicine flashcards USMLE® Step 1 flashcards
1
Q

General Appearance

drowsy or sleepy disposition

A

Somnolent

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2
Q

General Appearance

physically wasting (extremely thin)

A

Cachectic/Emaciated

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3
Q

General Appearance

Large body mass index (BMI)

A

Morbidly Obese

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4
Q

General Appearance

Well-appearing patient in minimal distress

(Often used to describe well-appearing pediatric patients)

A

Nontoxic Appearing

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5
Q

Head

normal appearance and size of the head

A

Normocephalic

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6
Q

Head

no signs of trauma present

A

Atraumatic

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7
Q

Skin

Bluish discoloration of the skin due to a lack of oxygen

A

Cyanosis

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8
Q

Skin

An unhealthy paleness of the skin

A

Pallor

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9
Q

Skin

Superficial reddening of the skin

A

Erythema

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10
Q

Skin

Yellowing of skin due to abnormal bilirubin build-up

A

Jaundice

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11
Q

Skin

Superficial wound to the top most layer of the skin

A

Abrasion

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12
Q

Skin

A region of skin in which blood capillaries are ruptured

(AKA bruise)

A

Contusion

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13
Q

Skin

An area of ruptured blood vessels similar to a contusion

(AKA bruise)

A

Ecchymosis

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14
Q

Skin

A cut in the the skin

A

Laceration

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15
Q

Skin

A small hole in the skin

A

Puncture

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16
Q

Skin

round, localized area of edema on the skin

A

Wheal

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17
Q

Skin

(a reaction) rash or hives

(irregular, blanch raised areas with redness)

A

Wheal-and-Flare

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18
Q

Skin

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

A

Urticaria

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19
Q

Skin

rash or hives

(flat red area covered with small confluent bumps)

A

Maculopapular

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20
Q

Skin

small collection of pus under the skin

A

Pustules

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21
Q

Skin

Fluid-filled blisters

A

Bullae

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22
Q

Skin

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

A

Petechiae

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23
Q

Skin

purple spots or blotches

(don’t turn white when pressed)

A

Purpura

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24
Q

Skin

A hardened area of normally soft tissue

A

Induration

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25
Q

Skin

Movable and compressible

A

Fluctuance

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26
Q

Skin

A benign tumor consisting of blood vessels

A

Hemangioma

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27
Q

Eyes

The transparent coat of the eyeball that covers the iris and pupil

(lets light into the eye)

A

Cornea

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28
Q

Eyes

The dense fibrous opaque outer coat enclosing the eyeball

(except the part covered by the cornea)

A

Sclera

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29
Q

Eyes

white area of the eyes

A

Conjunctiva

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30
Q

Eyes

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

A

Icterus

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31
Q

Eyes

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

A

Subconjunctival Hemorrhage

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32
Q

Eyes

appropriate function of the extraocular muscles

(tested with “follow my finger”)

A

Extraocular Movements Intact (EOMI)

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33
Q

Eyes

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

A

Pupils equal, round and reactive to light (PERRL)

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34
Q

Eyes

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

A

Papilledema

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35
Q

Eyes

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

A

Fundi Sharp

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36
Q

Eyes

acuteness / sharpness of vision as measured by the eye chart

A

Visual Acuity

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37
Q

Eyes

flipping the eyelid for exam underneath the eyelid

A

Eyelid Eversion

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38
Q

Eyes

eyelid membrane is clear

A

Normal Palpebral Conjunctiva

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39
Q

Eyes

bulging of eyes out of socket

A

Exophthalmos

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40
Q

Eyes

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

A

Nystagmus

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41
Q

Ears

redness of outer ear canal

A

Erythema of the External Canal

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42
Q

Ears

excessive earwax

A

Cerumen Impaction

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43
Q

Ears

Eardrum

A

Tympanic Membrane (TM)

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44
Q

Ears

red color of the TM

A

Erythematous TM

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45
Q

Ears

protruding / outward curvature of the TM

A

Bulging

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46
Q

Ears

inward curve of the TM

A

Retracted TM

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47
Q

Ears

cone of light does not reflect on TM

A

Poor Light Reflect

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48
Q

Ears

Provider cannot see landmarks behind TM

A

Unable to Visualize Landmarks

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49
Q

Ears

Blood on the TM

A

Hemotympanum

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50
Q

Ears

Tenderness over mastoid bone (located posterior to ear)

A

Mastoid Tenderness

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51
Q

Nose

clear nasal drainage

A

Clear Rhinorrhea

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52
Q

Nose

displacement of nasal septum

A

Septal Deviation

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53
Q

Nose

bruising or bleeding in the nasal septum

A

Septal Hematoma

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54
Q

Mouth

dry mouth

A

Dry Mucous Membranes

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55
Q

Mouth

cut on the tongue

A

Tongue Laceration

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56
Q

Mouth

no cuts/chipped teeth/etc.

A

No Signs of Oral Trauma

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57
Q

Mouth

Cavity

A

Dental Caries

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58
Q

Mouth

bad teeth

A

Poor Dentition

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59
Q

Mouth

infection of the gums

A

Pericoronitis

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60
Q

Mouth

enlargement of the parotid gland

A

Parotid Mass

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61
Q

Mouth

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

A

Trismus

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62
Q

Mouth

normal jaw alignment

A

Normal Jaw Approximation

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63
Q

Mouth

Malocclusion

A

misalignment of the teeth when mouth closed

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64
Q

Throat

no deviation of the uvula to one side or another

A

Uvula Midline

65
Q

Throat

redness of the throat

A

Pharyngeal Erythema

66
Q

Throat

pus seen on the posterior throat

A

Pharyngeal Exudate

67
Q

Throat

deep abscess adjacent to infected tonsils

(collection of pus/swelling which is usually only visible if drained)

A

Peritonsillar Abscess

68
Q

Neck

abnormal flow of blood through the carotid artery

A

Carotid Bruit

69
Q

Neck

swelling of the jugular vein

(usually seen in heart failure patients)

A

Jugular Vein Distension (JVD)

70
Q

Neck

pain along cervical spine

A

Cervical Vertebral Tenderness

71
Q

Neck

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

A

No Step-offs or crepitus

72
Q

Neck

swollen lymph nodes under jaw and along anterior neck area

A

Anterior Cervical Lymphadenopathy

73
Q

Neck

no deviation of trachea from its usual location

A

Trachea Midline

74
Q

Neck

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

A

Meningismus

75
Q

Neck

neck stiffness with neck movement

A

Nuchal Rigidity

76
Q

Chest Wall

gas or air present under the subcutaneous skin

A

Subcutaneous Emphysema

77
Q

Chest Wall

crackling/popping sensation that a provider feels under the skin due to air being present in skin tissue

A

Crepitus

(also reported as “crepitance”)

78
Q

Heart

Slow heart rate; less than 60 beats per minute

A

Bradycardia

79
Q

Heart

Fast heart rate; greater than 100 beats per minute

A

Tachycardia

80
Q

Heart

An abnormal sound heard when listening to the heart.

A

Murmur

81
Q

Heart

Heart murmur heard during systole

(active pumping)

A

Systolic Murmur

82
Q

Heart

Heart murmur heard during diastole

(rest/active filling)

A

Diastolic Murmur

83
Q

Heart

Faint-sounding heartbeat

A

Distant Heart Sounds

84
Q

Heart

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

A

Rubs

85
Q

Heart

extra/abnormal heart sounds

(should only hear 2 distinct sounds, but you hear 3 or 4 sounds)

A

Gallops

86
Q

Respiratory

Abnormally slow breathing

A

Bradypnea

87
Q

Respiratory

Abnormally rapid breathing

A

Tachypnea

88
Q

Respiratory

temporary absence or cessation of breathing

A

Apnea

89
Q

Respiratory

increased time between inspiratory and expiratory phases

A

Prolonged Inspiratory / Expiratory Phase

90
Q

Respiratory

using extra muscles to breathe

(usually see an emphasis on use of diaphragm and intercostal muscles)

A

Accessory Muscle Use

91
Q

Respiratory

wet, crackling sound with respirations

(aka crackles)

A

Rales

92
Q

Respiratory

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

A

Rhonchi

93
Q

Respiratory

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

A

Wheezes

94
Q

Respiratory

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

A

Stridor

95
Q

Respiratory

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

A

Intercostal Retractions

96
Q

Abdomen

bloating

A

Distension

97
Q

Abdomen

pregnant

A

Gravid

98
Q

Abdomen

accumulation of fluid in the peritoneal cavity

A

Ascites

99
Q

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

A

Tympanitic

100
Q

Abdomen

enlarged organ

A

Organomegaly

101
Q

Abdomen

enlarged liver

A

Hepatomegaly

102
Q

Abdomen

enlarged spleen

A

Splenomegaly

103
Q

Abdomen

pain in right upper quadrant that may indicate gallbladder infection

A

Murphy’s Sign

104
Q

Abdomen

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

A

Rovsing’s Sign

105
Q

Abdomen

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

A

Psoas Sign

106
Q

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)

A

Heel Tap Test

107
Q

Abdomen

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

A

McBurney’s Point Tenderness

108
Q

Abdomen

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

A

Umbilical hernia

109
Q

Abdomen

bruising in flank area (lower back area)

A

Grey Turner’s Sign

110
Q

Abdomen

bruising in the skin around the umbilicus

A

Cullen’s Sign

111
Q

Back

angle in back where kidneys are (HCP taps); left, right and bilateral

(if pain then possible kidney pathology)

A

Costovertebral Angle Tenderness (CVAT)

112
Q

Back

tenderness in muscles adjacent to spine

A

Paraspinal Muscle Tenderness

113
Q

Back

tenderness directly over spine

A

Midline Tenderness

114
Q

Back

no misalignment of thoracic/lumbar spine

A

No Step-offs

115
Q

Back

if pain, indicative of herniated disk

A

Straight Leg Raise

116
Q

Back

loss of sensation around buttocks area

A

Saddle Anesthesia

117
Q

Pelvic

pain with movement of cervix

A

Cervical Motion Tenderness (CMT)

118
Q

Pelvic

tenderness in location of the ovaries and fallopian tubes

A

Adnexal tenderness

119
Q

Pelvic

vaginal canal

A

Vaginal Vault

120
Q

Pelvic

cervical os (opening to cervix) is open or closed

A

Os Open/Closed

121
Q

Pelvic

product of conception (fetus, placenta, etc)

A

POC

122
Q

Genital

protrusion in the groin

A

Inguinal Hernia

123
Q

Genital

upward pull of testicles and scrotum due to touch

A

Cremasteric Reflex

124
Q

Genital

inability to pull back foreskin back over glans penis to its normal position

A

Paraphimosis

125
Q

Rectal

blood present/absent in stool

A

Guaiac (Hemoccult) positive/negative

126
Q

Rectal

tone of rectal muscles during digital exam

A

Rectal Tone

127
Q

Rectal

dark, tarry like stool containing blood

A

Melena

128
Q

Extremities

deformity of finger/fingernail due to chronic cyanosis

A

Clubbing

129
Q

Extremities

rotation of knee causes pain

A

McMurray’s Test

130
Q

Extremities

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

A

Snuff Box Tenderness

131
Q

Extremities

pivot shift test causes pain

A

Lachman’s Test

132
Q

Extremities

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

A

Median/Ulnar/Radial Sensory Function

133
Q

Extremities

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

A

Pain Out of Proportion

134
Q

Extremities

evaluation for knee instability

A

Valgus/Varus Stress Test

135
Q

Extremities

pain in calf or popliteal region

A

Homan’s Sign

136
Q

Extremities

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

A

Pitting Edema

137
Q

Extremities

above / below knee amputation

(Indicate R or L)

A

AKA / BKA

138
Q

Extremities

loose ligaments

A

Ligamentous Laxity

139
Q

Extremities

small fluid filled sack surrounding a joint

A

Bursa

140
Q

Neurologic

Loss of ability to express or understand speech

A

Aphasia

141
Q

Neurologic

having a difficult time finding what words to say

A

Dysphasia

142
Q

Neurologic

difficult time communicating or articulation

(i.e. slurred speech)

A

Dysarthria

143
Q

Neurologic

Patient moves upon painful stimulation

A

Purposeful Movements

144
Q

Neurologic

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

A

Glasgow Coma Scale (GCS)

145
Q

Neurologic

withdraws extremity where painful stimulation is applied

A

Localizes to Pain

146
Q

Neurologic

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

A

Grip Strength

147
Q

Neurologic

hold palms out upwards and look for movement of palms

(rotation)

A

Pronator Drift

148
Q

Neurologic

finger to nose exam

A

Dysmetria

149
Q

Neurologic

inability to perform rapid alternating movements

A

Dysdiadochokinesia

150
Q

Neurologic

walking abnormally and/or unsteadily

A

Ataxic Gait

151
Q

Neurologic

test for coordination

A

Heel to Shin Test

152
Q

Neurologic

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

A

Romberg’s Test

153
Q

Neurologic

tests the stability of a patient’s gait

A

Heel Toe Gait

154
Q

Neurologic

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

A

Babinski Sign

155
Q

Neurologic

involuntary/instantaneous movement

A

Reflexes

156
Q

Psychiatric

the observed emotional state of a person

A

Affect

157
Q

Psychiatric

orientation to person, place, time, and event

(A/O x 4)

A

Orientation

158
Q

Psychiatric

an experience involving the apparent perception of something not present

A

Hallucinations (auditory or visual)

159
Q

Psychiatric

thoughts of suicide / thoughts of homicide

A

Suicidal (SI) /Homicidal Ideation (HI)

Medical Scribe: Emergency Department (1 decks)

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