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ScribeAmerica ED Classroom Training > Course 4: Physical Exam > Flashcards

Course 4: Physical Exam Flashcards

1
Q

Objective Information

A

Physical exam, Lab results, Imaging results

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2
Q

What is a physical exam?

A

Inspection by the physician of patient’s body systems by inspection, palpation, and auscultation

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3
Q

Inspection

A

Examination by sight

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4
Q

Palpation

A

Examination by touch

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5
Q

Auscultation

A

Examination by listening (with a stethoscope)

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6
Q

Why is the physical exam important?

A

The physical exam allows the physician to investigate patient complaints and narrow down/rule out diagnoses

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7
Q

What is the scribe’s responsibility for the physical exam?

A

Document all physical exam findings as the physician is performing the exam

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8
Q

What does belong in the physical exam section of the chart

A

What the physician:

  • Saw
  • Heard
  • Felt
  • Smelled
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9
Q

What does not belong in the physical exam section of the chart

A
  • Symptoms
  • Medical history
  • Diagnoses
  • Any component not inspected
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10
Q

Right

A

Patient’s right side

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11
Q

Left

A

Patient’s left side

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12
Q

Anterior

A

Front

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13
Q

Posterior

A

Back

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14
Q

Proximal

A

Near point of attachment

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15
Q

Distal

A

Far from point of attachment

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16
Q

Medial

A

Near midline

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17
Q

Lateral

A

Far from midline

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18
Q

Superior

A

Above

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19
Q

Inferior

A

Below

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20
Q

Focal

A

One area

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21
Q

Diffuse

A

Widespread

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22
Q

Palmar

A

Palm of hand

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23
Q

Plantar

A

Sole of foot

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24
Q

Supeficial

A

On the surface/shallow

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25
Deep
Away from the surface/further into the body
26
Body Systems
Constitutional, Eyes, ENT (Ears/Nose/Throat), Neck, Cardiovascular, Pulmonary, Gastrointestinal, Genitourinary, Musculoskeletal, Skin, Lymphatic, Neurological, Psychological
27
Vital Signs
Blood Pressure, Heart Rate, Respiratory Rate, Temperature, Oxygen Saturation
28
Blood Pressure
Normal: 120/80 Low: Hypotensive High: Hypertensive
29
Heart Rate
Normal: 60-100 bpm Low: Bradycardic High: Tachycardic
30
Respiratory Rate
Normal: 12-18 breaths per minute Low: Bradypneic High: Tachypneic
31
Temperature
Normal: 98.6 °F Low: Hypothermic High: Febrile (above 100.4 °F)
32
Oxygen Saturation
Normal: \> 96% Low: Hypoxic (\< 92%)
33
Distress Level Normal (Constitutional)
No acute distress (NAD)
34
Distress Level Abnormal (Constitutional)
Mild/moderate/severe distress due to pain or respiratory difficulty
35
Distress Level Method of Investigation (Constitutional)
Visual
36
General Appearance Normal (Constitutional)
Well developed, Well nourished
37
General Appearance Abnormal (Constitutional)
Cachectic/Emaciated/Malnourished
38
General Appearance Method of Investigation (Constitutional)
Visual
39
Awareness Normal (Constitutional)
Alert
40
Awareness Abnormal (Constitutional)
Somnolent, Obtunded, Unresponsive
41
Awareness Method of Investigation (Constitutional)
Visual
42
Pupils Normal (Eyes)
Pupils Equal, Round, and Reactive to Light (PERRL)
43
Pupils Abnormal (Eyes)
Fixed and dilated → Stroke, tumor, brain injury, congenital
44
Pupils Method of Investigation (Eyes)
Visual (shines light in patient's eye)
45
Extraocular Movements Normal (Eyes)
Extraocular movements intact (EOMI)
46
Extraocular Movements Abnormal (Eyes)
EOM entrapment
47
Extraocular Movements Method of Investigation (Eyes)
Visual (has patient track finger)
48
Nystagmus Normal (Eyes)
No nystagmus
49
Nystagmus Abnormal (Eyes)
Nystagmus → Inner ear problem, alcohol or drug use, abnormal brain conditions
50
Nystagmus Method of Investigation (Eyes)
Visual (has patient track finger)
51
Sclera Normal (Eyes)
Sclerae anicteric
52
Sclera Abnormal (Eyes)
Scleral icterus → Liver failure
53
Sclera Method of Investigation (Eyes)
Visual
54
Conjunctiva Normal (Eyes)
Normal conjunctiva
55
Conjunctiva Abnormal (Eyes)
Pale conjunctiva → Anemia Conjunctival injection → Conjunctivitis Discharge or crusting → Infection
56
Conjunctiva Method of Investigation (Eyes)
Visual
57
Tympanic Membrane (TM) Normal (Ears)
Tympanic membranes (TMs) normal
58
Tympanic Membrane (TM) Abnormal (Ears)
TM erythema, effusion, bulging, dullness → Otitis media TM obscured by cerumen → Cannot see TM because of earwax
59
Tympanic Membrane (TM) Method of Investigation (Ears)
Visual (places otoscope in patient's ear)
60
Ear Canal Normal (Ears)
No canal swelling or tenderness
61
Ear Canal Abnormal (Ears)
Canal swelling or tenderness → Otitis externa
62
Ear Canal Method of Investigation (Ears)
Visual (places otoscope in patient's ear)
63
Discharge Normal (Nose)
No discharge
64
Discharge Abnormal (Nose)
Clear or yellow discharge
65
Discharge Method of Investigation (Nose)
Visual
66
Nasal Mucosa Normal (Nose)
Normal nasal mucosa
67
Nasal Mucosa Abnormal (Nose)
Boggy turbinates/Swelling of the nasal mucosa → Rhinitis
68
Nasal Mucosa Method of Investigation (Nose)
Visual (places otoscope in patient's nare(s))
69
Nose Bleeding Normal (Nose)
No active bleeding
70
Nose Bleeding Abnormal (Nose)
Site of bleeding identified → Epistaxis
71
Nose Bleeding Method of Investigation (Nose)
Visual (places otoscope in patient's nare(s))
72
Mucous Membranes Normal (Throat and Mouth)
Moist mucous membranes
73
Mucous Membranes Abnormal (Throat and Mouth)
Dry mucous membranes → Dehydrated
74
Mucous Membranes Method of Investigation (Throat and Mouth)
Visual (has patient open mouth)
75
Oropharynx Normal (Throat and Mouth)
Oropharynx normal
76
Oropharynx Abnormal (Throat and Mouth)
Pharyngeal erythema → Pharyngitis Exudates → Pharyngitis, tonsillitis Tonsillar hypertrophy → Tonsillitis Tonsillar asymmetry → Peritonsillar abscess Uvular shift → Peritonsillar abscess
77
Oropharynx Method of Investigation (Throat and Mouth)
Visual (has patient open mouth, usually uses a light)
78
Dentition Normal (Throat and Mouth)
Normal dentition
79
Dentition Abnormal (Throat and Mouth)
Edentulous → No teeth Dental caries → Cavities Gum tenderness or edema → Infection
80
Dentition Method of Investigation (Throat and Mouth)
Visual (has patient open mouth, usually uses a light)
81
Range of Motion Normal (Neck)
Normal range of motion
82
Range of Motion Abnormal (Neck)
Limited range of motion
83
Range of Motion Method of Investigation (Neck)
Visual (has patient move neck)
84
Meningismus Normal (Neck)
Supple; no meningismus
85
Meningismus Abnormal (Neck)
Nuchal rigidity; meningismus
86
Meningismus Method of Investigation (Neck)
Visual (has patient move neck)
87
Tenderness Normal (Neck)
No tenderness
88
Tenderness Abnormal (Neck)
Vertebral point tenderness → Fracture Paraspinal tenderness → Muscle strain
89
Tenderness Method of Investigation (Neck)
Palpates neck
90
Lymph Nodes Normal (Neck)
No cervical lymphadenopathy
91
Lymph Nodes Abnormal (Neck)
Anterior and/or posterior cervical lymphadenopathy → Infection
92
Lymph Nodes Method of Investigation (Neck)
Palpates side of neck
93
Jugular Vein Distension (JVD) Normal (Neck)
No jugular vein distension (JVD)
94
Jugular Vein Distension (JVD) Abnormal (Neck)
Jugular vein distension (JVD) → Heart failure
95
Jugular Vein Distension (JVD) Method of Investigation (Neck)
Visual
96
Carotid Bruit Normal (Neck)
No carotid bruit
97
Carotid Bruit Abnormal (Neck)
Carotid bruit → Carotid artery stenosis
98
Carotid Bruit Method of Investigation (Neck)
Auscultates (places stethoscope to neck)
99
Rate Normal (Cardiovascular)
Regular rate
100
Rate Abnormal (Cardiovascular)
Tachycardia (\> 100 bpm) Bradycardia (\< 60 bpm)
101
Rate Method of Investigation (Cardiovascular)
Auscultate (places stethoscope to chest)
102
Rhythm Normal (Cardiovascular)
Regular rhythm
103
Rhythm Abnormal (Cardiovascular)
Irregularly irregular rhythm → A fib
104
Rhythm Method of Investigation (Cardiovascular)
Auscultate (places stethoscope to chest)
105
Sounds Normal (Cardiovascular)
Heart sounds normal
106
Sounds Abnormal (Cardiovascular)
Murmurs → 2/6 systolic ejection murmur Rubs → Pericarditis Gallops → Ventricular failure or hypertrophy Extrasystoles
107
Sounds Method of Investigation (Cardiovascular)
Auscultate (places stethoscope to chest)
108
Pulses Normal (Cardiovascular)
2+ (easily palpable, normal)
109
Pulses Abnormal (Cardiovascular)
0 → Absent pulse 1+ → Barely palpable 3+ → Full 4+ → Bounding/aneurysmal
110
Pulses Method of Investigation (Cardiovascular)
Palpates pulse in a specific location: * Carotid - Neck * Radial - Wrist * Femoral - Groin * Dorsalis pedis (DP) - Top of the foot * Posterior tibial (PT) - Back of the ankle
111
Capillary Refill Normal (Cardiovascular)
Capillary refill less than 2 seconds
112
Capillary Refill Abnormal (Cardiovascular)
Delayed capillary refill → Decreased blood flow or dehydration
113
Capillary Refill Method of Investigation (Cardiovascular)
Visual (presses on finger or toes)
114
Respiratory Distress Normal (Respiratory)
No respiratory distress
115
Respiratory Distress Abnormal (Respiratory)
Mild/moderate/severe respiratory distress Tachypnea Accessory muscle use Pursed lip breathing → Emphysema
116
Respiratory Distress Method of Investigation (Respiratory)
Visually
117
Lung Auscultation Normal (Respiratory)
Clear to auscultation bilaterally
118
Lung Auscultation Abnormal (Respiratory)
Diminished breath sounds Wheezes → Asthma or COPD Rales/crackles → CHF Rhonchi → Pneumonia
119
Lung Auscultation Method of Investigation (Respiratory)
Auscultate (places stethoscope to back)
120
Softness Normal (Gastrointestinal)
Soft
121
Softness Abnormal (Gastrointestinal)
Rigidity
122
Softness Method of Investigation (Gastrointestinal)
Palpates abdomen
123
Tenderness Normal (Gastrointestinal)
Nontender
124
Tenderness Abnormal (Gastrointestinal)
Mild/moderate/severe tenderness 3 peritoneal signs: 1. Guarding 2. Rebound 3. Rigidity
125
Tenderness Method of Investigation (Gastrointestinal)
Palpates abdomen
126
Murphy's Sign Normal (Gastrointestinal)
Negative Murphy's sign
127
Murphy's Sign Abnormal (Gastrointestinal)
Positive Murphy's sign → Cholecystitis
128
Murphy's Sign Method of Investigation (Gastrointestinal)
Palpates specific place in RUQ
129
McBurney's Point Tenderness Normal (Gastrointestinal)
Negative McBurney's point tenderness
130
McBurney's Point Tenderness Abnormal (Gastrointestinal)
Positive McBurney's point tenderness → Appendicitis
131
McBurney's Point Tenderness Method of Investigation (Gastrointestinal)
Palpates McBurney's point (RLQ)
132
Bowel Sounds Normal (Gastrointestinal)
Normal bowel sounds
133
Bowel Sounds Abnormal (Gastrointestinal)
Absent/hypoactive/hyperactive bowel sounds
134
Bowel Sounds Method of Investigation (Gastrointestinal)
Auscultate (places stethoscope to abdomen)
135
Organomegaly Normal (Gastrointestinal)
No organomegaly
136
Organomegaly Abnormal (Gastrointestinal)
Hepatomegaly Splenomegaly
137
Organomegaly Method of Investigation (Gastrointestinal)
Palpates abdomen
138
Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Normal (Musculoskeletal)
Nontender thoracic spine (T-spine) and lumbar spine (L-spine)
139
Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Abnormal (Musculoskeletal)
Paraspinal tenderness (muscle injury) Vertebral point tenderness (spinal injury)
140
Thoracic Spine (T-Spine) and Lumbar Spine (L-Spine) Tenderness Method of Investigation (Musculoskeletal)
Palpates specific area of concern
141
Costovertebral Angle (CVA) Tenderness Normal (Musculoskeletal)
No costovertebral angle (CVA) tenderness
142
Costovertebral Angle (CVA) Tenderness Abnormal (Musculoskeletal)
Costovertebral angle tenderness → Kidney stone, pyelonephritis
143
Costovertebral Angle (CVA) Tenderness Method of Investigation (Musculoskeletal)
Palpates specific area of concern
144
Extremity Tenderness Normal (Musculoskeletal)
No tenderness to the extremities
145
Extremity Tenderness Abnormal (Musculoskeletal)
Bony tenderness → Fracture Soft tissue tenderness → Contusion, strain Calf tenderness → DVT
146
Extremity Tenderness Method of Investigation (Musculoskeletal)
Palpates specific area of concern
147
Edema Normal (Musculoskeletal)
No edema
148
Edema Abnormal (Musculoskeletal)
Edema (trace to 4+) → CHF
149
Edema Method of Investigation (Musculoskeletal)
Visual and sometimes palpation
150
Range of Motion (ROM) Normal (Musculoskeletal)
Normal range of motion (ROM)
151
Range of Motion (ROM) Abnormal (Musculoskeletal)
Limited range of motion (ROM) secondary to pain
152
Range of Motion (ROM) Method of Investigation (Musculoskeletal)
Visual (has patient move joint)
153
CMST (Circulation, Sensory, Motor, Tendon) Normal (Musculoskeletal)
Distal CMST intact
154
CMST (Circulation, Sensory, Motor, Tendon) Abnormal (Musculoskeletal)
Pulse/sensory/motor deficits Tendon laxity
155
CMST (Circulation, Sensory, Motor, Tendon) Method of Investigation (Musculoskeletal)
Palpates distally to the specific area of concern
156
Warmth Normal (Skin/Integumentary)
Warm
157
Warmth Abnormal (Skin/Integumentary)
Cool to touch Hot to touch → Febrile/infection
158
Warmth Method of Investigation (Skin/Integumentary)
Palpates skin
159
Wetness Normal (Skin/Integumentary)
Dry
160
Wetness Abnormal (Skin/Integumentary)
Diaphoretic
161
Wetness Method of Investigation (Skin/Integumentary)
Visual
162
Color Normal (Skin/Integumentary)
Normal color
163
Color Abnormal (Skin/Integumentary)
Jaundice (yellow) → Liver failure Cyanotic (blue) → Hypoxic Pallor → Anemia
164
Color Method of Investigation (Skin/Integumentary)
Visual
165
Rashes Normal (Skin/Integumentary)
No rashes
166
Rashes Abnormal (Skin/Integumentary)
Urticaria/wheals/maculopapular rash Petechiae
167
Rashes Method of Investigation (Skin/Integumentary)
Visual and sometimes palpates skin
168
Induration/Fluctuance/Purulent Drainage Normal (Skin/Integumentary)
No induration No fluctuance No purulent drainage
169
Induration/Fluctuance/Purulent Drainage Abnormal (Skin/Integumentary)
Induration → Cellulitis Fluctuance → Abscess Purulent drainage → Abscess
170
Induration/Fluctuance/Purulent Drainage Method of Investigation (Skin/Integumentary)
Visual and sometimes palpates skin
171
Alertness Normal (Neurological)
Alert
172
Alertness Abnormal (Neurological)
Somnolent (drowsy) Confused Responsive to voice Responsive to painful stimuli Unresponsive to voice and pain
173
Alertness Method of Investigation (Neurological)
Converses with patient
174
Orientation Normal (Neurological)
Oriented x4
175
Orientation Abnormal (Neurological)
Disoriented to person, place, time, or situation
176
Orientation Method of Investigation (Neurological)
Asking: * What's your name? * Where are you? * What year is it? * Why are you here?
177
Speech Normal (Neurological)
Speech
178
Speech Abnormal (Neurological)
Aphasia (expressive or receptive) → CVA Dysarthria
179
Speech Method of Investigation (Neurological)
Person is able to speak and understand when spoken to
180
Cranial Nerves Normal (Neurological)
Cranial nerves 2 to 12 intact
181
Cranial Nerves Abnormal (Neurological)
Provider will specify; examples of cranial nerve deficits may be visual field loss, unequal pupils, facial droop, EOM palsy, or facial hypoesthesia
182
Cranial Nerves Method of Investigation (Neurological)
Varies
183
Motor Strength Normal (Neurological)
Motor strength 5/5 and symmetric
184
Motor Strength Abnormal (Neurological)
Pronator drift Grip or lower extremity strength: * 4/5 = Very mildly weak * 3/5 = Unable to overcome resistance * 2/5 = Unable to overcome gravity * 1/5 = Slight contraction, no movement * 0/5 = Flaccid, limp
185
Motor Strength Method of Investigation (Neurological)
Pronator drift - Visual Grip or lower extremity strength is felt by the physician
186
Sensation Normal (Neurological)
Sensation intact
187
Sensation Abnormal (Neurological)
Hypoesthesia (decreased sensation) Numbness (absent sensation)
188
Sensation Method of Investigation (Neurological)
Asking patient if it feels normal and the same on both sides
189
Reflexes Normal (Neurological)
Reflexes 2+ and symmetric
190
Reflexes Abnormal (Neurological)
0 = Absent 1+ = Hypoactive 3+ = Increased 4+ = Unsustained clonus
191
Reflexes Method of Investigation (Neurological)
Visual - Uses a rubber mallet to strike different points on the individual's body and observes the response: * Tricep * Bicep * Brachioradialis * Patellar * Achilles
192
Gait Normal (Neurological)
Normal gait
193
Gait Abnormal (Neurological)
Ataxia (uncoordinated) Antalgic (walking to avoid pain)
194
Gait Method of Investigation (Neurological)
Visual (asks patient to walk)
195
Nystagmus Normal (Neurological)
No nystagmus
196
Nystagmus Abnormal (Neurological)
Nystagmus
197
Nystagmus Method of Investigation (Neurological)
Visual (asks patient to track finger)
198
Coordination Normal (Neurological)
Normal finger-to-nose Normal heel-to-shin
199
Coordination Abnormal (Neurological)
Dysmetria
200
Coordination Method of Investigation (Neurological)
Visual (asks patient to touch finger to nose) Visual (asks patient to rub heel down their shin)
201
Romberg's Normal (Neurological)
Negative Romberg's
202
Romberg's Abnormal (Neurological)
Positive Romberg's
203
Romberg's Method of Investigation (Neurological)
Visual (asks patient to stand with arms out)
204
Trauma Exam Head
Battle's sign, Raccoon eyes, Periorbital ecchymosis
205
Trauma Exam Eyes
Unequal pupils, Subconjunctival hemorrhage, Hyphema
206
Trauma Exam ENT
Hemotympanum, Nasal bone deformity, Epistaxis, Septal hematoma, Malocclusion, Dental injury
207
Trauma Exam Neck
C-collar in place, Vertebral point tenderness, Step-offs
208
Trauma Exam Pulmonary
Absent breath sounds, Splinting, Crepitus
209
Trauma Exam Gastrointestinal
Tenderness, Distended, Ecchymoses
210
Trauma Exam Musculoskeletal
Pelvis unstable, Bony tenderness, Deformities, Vertebral point tenderness, Step-offs
211
Trauma Exam Skin
Ecchymosis, Laceration, Abrasion, Skin tear, Avulsion
212
Trauma Exam Neurological
Glasgow Coma Scale (GCS \< 15)
213
Code Exam Constitutional
Unresponsive
214
Code Exam Head
Normocephalic, Atraumatic
215
Code Exam Eyes
Fixed and dilated
216
Code Exam ENT
Airway patent, ETT in place
217
Code Exam Cardiovascular
Absent heart sounds, No palpable pulses
218
Code Exam Pulmonary
No spontaneous respirations, Equal with controlled ventilation
219
Code Exam Musculoskeletal
No deformities
220
Code Exam Skin
Pallor, Cyanotic, Mottled
221
Code Exam Neurological
Unresponsive, Neurological exam limited due to clinical condition
222
Pediatric Exam Constitutional
Non-toxic, Alert, Interactive, Playful, Smiling, Crying with tears on exam, Quickly consolable
223
Pediatric Exam Head
Flat fontanel (if less than 8 months old)
224
Pediatric Exam Eyes
PERRL, No scleral icterus
225
Pediatric Exam ENT
Normal tympanic membranes (TMs), Moist mucous membranes
226
Pediatric Exam Neck
Supple, No meningismus
227
Pediatric Exam Cardiovascular
Regular rate and rhythm, No murmurs
228
Pediatric Exam Pulmonary
No distress, Clear to auscultation bilaterally, No wheezes, No stridor
229
Pediatric Exam Gastrointestinal
Soft, No crying or grimacing with palpation
230
Pediatric Exam Musculoskeletal
Full range of motion (FROM)
231
Pediatric Exam Skin
Warm and dry, No rash
232
Pediatric Exam Neurological
Alert, Appropriate for age, Moves all 4 extremities
233
Heme Normal (Rectal)
Heme negative
234
Heme Abnormal (Rectal)
Heme positive → GI bleed
235
Heme Method of Investigation (Rectal)
Heme occult test
236
Stool Color Normal (Rectal)
Brown stool
237
Stool Color Abnormal (Rectal)
Black/melanotic, red, yellow, white, bright red
238
Stool Color Method of Investigation (Rectal)
Visual (stool sample)
239
Hemorrhoids Normal (Rectal)
No hemorrhoids
240
Hemorrhoids Abnormal (Rectal)
Hemorrhoids (internal, external, thrombosed)
241
Hemorrhoids Method of Investigation (Rectal)
Palpates rectum
242
Tone Normal (Rectal)
Normal tone
243
Tone Abnormal (Rectal)
Decreased rectal tone → Spinal cord injury
244
Tone Method of Investigation (Rectal)
Palpates rectum
245
External Genitalia Normal (Female Genitourinary)
Normal external genitalia
246
External Genitalia Abnormal (Female Genitourinary)
Sores, lesions, rashes
247
External Genitalia Method of Investigation (Female Genitourinary)
Visual
248
Tenderness Normal (Female Genitourinary)
No tenderness
249
Tenderness Abnormal (Female Genitourinary)
Cervical motion tenderness (CMT) → Pelvic inflammatory disease Uterine tenderness Adnexal tenderness → Ovarian cysts
250
Tenderness Method of Investigation (Female Genitourinary)
Bimanual
251
Cervical Os Normal (Female Genitourinary)
Cervical os is closed
252
Cervical Os Abnormal (Female Genitourinary)
Cervical os is open
253
Cervical Os Method of Investigation (Female Genitourinary)
Visual (uses speculum)
254
Blood/Discharge Normal (Female Genitourinary)
No blood or discharge
255
Blood/Discharge Abnormal (Female Genitourinary)
Blood in the vaginal vault Malodorous/thick white discharge
256
Blood/Discharge Method of Investigation (Female Genitourinary)
Visual (uses speculum)
257
External Genitalia Normal (Male Genitourinary)
Normal external genitalia
258
External Genitalia Abnormal (Male Genitourinary)
Sores, lesions, rashes
259
External Genitalia Method of Investigation (Male Genitourinary)
Visual
260
Tenderness Normal (Male Genitourinary)
No tenderness
261
Tenderness Abnormal (Male Genitourinary)
Testicular tenderness Epididymal tenderness
262
Tenderness Method of Investigation (Male Genitourinary)
Palpates testicles
263
Edema Normal (Male Genitourinary)
No edema
264
Edema Abnormal (Male Genitourinary)
Testicular edema
265
Edema Method of Investigation (Male Genitourinary)
Visual
266
Discharge Normal (Male Genitourinary)
No discharge
267
Discharge Abnormal (Male Genitourinary)
Urethral discharge → Infection
268
Discharge Method of Investigation (Male Genitourinary)
Visual
269
Mass Normal (Male Genitourinary)
No mass
270
Mass Abnormal (Male Genitourinary)
Inguinal hernia Testicular mass
271
Mass Method of Investigation (Male Genitourinary)
Palpates testicles and inguinal region
272
Affect Normal (Psychological)
Normal affect
273
Affect Abnormal (Psychological)
Odd affect, flat affect, depressed affect
274
Affect Method of Investigation (Psychological)
Converses with patient
275
Suicidal/Homicidal Ideation (SI/HI) Normal (Psychological)
No suicidal ideation (SI) or homicidal ideation (HI)
276
Suicidal/Homicidal Ideation (SI/HI) Abnormal (Psychological)
Suicidal or homicidal with or without plan
277
Suicidal/Homicidal Ideation (SI/HI) Method of Investigation (Psychological)
Patient states
278
Hallucinations Normal (Psychological)
No auditory or visual hallucinations
279
Hallucinations Abnormal (Psychological)
Auditory or visual hallucinations
280
Hallucinations Method of Investigation (Psychological)
Converses with patient

ScribeAmerica ED Classroom Training (5 decks)

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