Class 4 Flashcards
(92 cards)
1
Q
What is included in the objective portion of the chart?
A
healthcare provider’s observations
diagnostic tests
vital signs
2
Q
What are elements of the PE?
A
inspection (looking)
palpation (feeling)
auscultation (listening)
3
Q
What is the only thing that belongs in the PE portion of the chart?
A
only things that the physician saw, heard, felt or smelled
should not include any subjective information or PMHx
4
Q
Front
A
anterior
5
Q
Back
A
posterior
6
Q
near point of attachment
A
proximal
7
Q
far from point of attachment
A
distal
8
Q
near midline
A
midal
9
Q
far from midline
A
lateral
10
Q
above
A
superior
11
Q
below
A
inferior
12
Q
one area
A
focal
13
Q
widespread
A
diffuse
14
Q
palm of hand
A
palmar
15
Q
sole of foot
A
plantar
16
Q
surface
A
superficial
17
Q
What is the physical exam grouped by?
A
body systems
18
Q
What are the 5 vital signs?
A
BP, HR (pulse rate), RR, T, SaO2 (SpO2)
19
Q
What are abnormal pulse rates?
A
Bradycardic (below 60 bpm)
Tachycardic (above 100 bpm)
20
Q
What are abnormal RR?
A
Bradypneic (below 12 bpm)
Tachypneic (above 18 bpm)
21
Q
Constitutional meanig
A
the general appearance of patient
these findings are typically appreciated without touching the patient
22
Q
What would contradict “alert” ?
A
somnolent, obtunded, unresponsive
23
Q
What would contradict “well developed, well nourished” ?
A
Cachectic, emaciated, malnourished
24
Q
What is being invesitgated in constitutional part of PE?
A
distress level, general appearance, smell
25
What is being investigated in eye portion of PE?
pupils, sclera, conjunctiva, movement
26
What is being investigated in ENT portion of PE?
outer ear, inner ear, nares, dentition, oropharnyx
27
How do you examine the inner ear?
use an ophthalmoscope
28
What is sclera?
the white of eye
29
What is being investigated in neck portion of PE?
lympth nodes, thyroid, carotid artery, jugular vein, vertebrae, muscles
30
What is being investigated in cardiovascular portion of PE?
rate and rhythmn (assessed with stethoscope)
pulses
31
What is being assessed in pulmonary portion of the exam?
Respiratory distress, breath sounds
32
What is being investigated in GI portion of PE?
Tenderness, enlarged organs, bowel sounds
33
What is being assessed in GU portion of PE?
masses, skin or mucosal findings, bleeding
34
What is being assessed in musculoskeletal portion of PE?
bones or muscle tenderness, deformity, range of motionn
35
What is being assessed in skin portion of the PE?
rashes, infections, trauma
36
What is being assessed in lymphatic portion of PE?
lymph node
37
What is being assessed in neurological portion of PE?
mental stautes, alertness, speech, vision, coordination, memory
38
What is being assessed in psychological portion of PE?
behavior, mood and affect
39
What is a normal status for pupils?
PERRL (pupils equal, round and reactive to light)
40
What is an abnormal status for pupils?
fixed and dilated
41
What is a normal status for eye movement?
EOMI
42
What is an abnormal status for eye movement?
EOM
43
What is normal for sclerae?
sclerae anicteric
44
What is abnormal for sclerae?
scleral icterus
45
What does scleral icterus indicate?
liver failure
46
What is normal for conjunctiva?
normal conjunctiva
47
What is abnormal for conjunctiva?
pale, conjunctival injection, subconjunctival hemorrhage, discharge or crusting
48
What is normal for tympanic membranes?
TMs normal
49
What is abnormal for tympanic membraes?
anything other than TM normal
50
What 3 things are normal for the nose?
no discharge, normal nasal mucosa, no active bleeding
51
What is not normal for nasal mucosa?
boggy turbinates / swelling of the nasal mucosa
52
What does the suffix -itis mean?
inflammation
53
What is normal for the throat and mouth?
moist mucous membranes, oropharnyx normal, normal dentition
54
What is abnormal for the oropharnyx?
pharyngeal erythema, exudates, tonsillar hypertrophy, tonsillar asymmetry, uvular shift
55
What is abnormal for dentition?
edentulous (no teeth), dental caries (cavities)
56
What is normal for the neck?
supple, no meningismus, no tenderness, no cervical lymphadenopathy, no jugular vein distension, no thyromegaly, no carotid bruit
57
What is abnormal for meningismus?
positive Brudzinski's sign which indicates meningitis
58
What is abnormal for tenderness of the neck?
vertebral point (fracture), paraspinal tenderness (muscle strain)
59
What is an abnormal rhythm for cardiovascular?
irregularly irregular rhythm
60
What is opposite of normal heart sounds?
murmurs, rubs, and gallops
61
What is normal for pulses?
2+ (easily palpable / normal)
Capillary refill less than 2 seconds
62
Where can pulses be found?
carotid, radial, femoral, dorsalis pedis, posterior tibial
63
Carotid
neck
64
radial
wrist
65
femoral
groin
66
dorsalis pedis
top of foot
67
posterior tibial
back of the ankle
68
What is normal for respiratory portion of PE?
no respiratory distress, clear to auscultation bilaterally
69
What is abnormal to respiratory distress?
respiratory distress, tachypnea, accessory muscle use, pursed lip breathing
70
What is abnormal to "clear to auscultation bilaterally" ?
diminished breath sounds, wheezes, rales (crackles), rhonchi
71
What is normal for GI portion of PE?
soft, nontender, negative Murphy's sign, negative McBurney's point tenderness, normal bowel sounds, no organomegaly, no masses
72
What is opposite of soft abdomen
Distended
73
What are the four regions of the abdomen?
RUQ, LUQ, RLQ, LLQ
74
What does a positive Murphy's sign indicate?
cholecystitis
75
Where do you palpate for Murphy's sign?
RUQ
76
What does a positive McBurney's point tenderness indicate?
appendicitis
77
What is the opposite of no organomegaly?
hepatomegaly, splenomegaly
78
What is normal for musculoskeletal portion of PE?
no tenderness, no edema, normal ROM, distal CSMT intact
79
What is normal for the skin portion of PE?
warm, dry, normal color, no rashes, no induration, no fluctuance
80
What is the opposite of dry skin?
diaphoretic
81
What is the opposite of normal color skin?
Juandice, cyanotic, pallor
82
What does pallor skin indicate?
anemia
83
What does cyanotic skin indicate?
hypoxia
84
What is the opposite of no rashes?
Urticaria / Wheals
Petechiae
85
What is normal for neurological exam?
Alert and oriented x4, speech, motor strength 5/5 and symmetric, sensation intact, reflexes 2+ and symmetric
86
How should reflexes be?
2+ and symmetric
87
What is abnormal sensation?
Hypoesthesia, numbness
88
What is normal for motor strength?
5/5 and symmetric
89
What is pronator drift?
one arm dips lower than the other when holding them up
90
What is abnormal for alertness?
somnolent, confused, responsive to voice, responsive to painful stimuli, unresponsive to voice or pain
91
What are the four things that we measure orientation to?
person, place, time or situation
92
What is abnormal for speech?
aphasia, dysarthria
