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Scribe America ED > Day 4: Exam Findings > Flashcards

Day 4: Exam Findings Flashcards

(98 cards)

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1
Q

Normal Finding: General

A

No acute distress, well developed, well nourished

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2
Q

Normal Finding: Eyes

A

PERRL – Pupils Equal, Round, Reactive to Light

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3
Q

Normal Finding: ENT

A

Moist mucosa

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4
Q

Normal Finding: Neck

A

supple

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5
Q

Normal Finding: Cardiovascular

A

well perfused

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6
Q

Normal Finding: Respiratory

A

no respiratory distress

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7
Q

Normal Finding: Abdominal

A

non-distended

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8
Q

Normal Finding: Extremities

A

no edema

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9
Q

Normal Finding: Skin

A

warm, dry

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10
Q

Normal Finding: Neurological

A

Alert and Oriented. Normal speech

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11
Q

Normal Finding: Psychiatric

A

normal affect

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12
Q

4 actions of a typical physical exam

A
  1. Assessing pt’s external appearance and mental status
  2. Auscultating the pt’s heart and lungs
  3. Palpating the abdomen
  4. Examining the pt’s legs
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13
Q

Normal Finding: Constitutional

A

No acute distress, well developed, well nourished

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14
Q

Normal Finding: Cardiovascular PE

A

Regular rate/rhythm. No murmurs, rubs, or gallops. Distal pulses intact.

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15
Q

Normal Finding: Respiratory PE

A

No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

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16
Q

Normal Finding: Abdominal PE

A

Soft. Non-tender. Non-distended. No guarding, rebound, or rigidity.

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17
Q

External Inspection

A

No acute distress. Well-developed, well nourished. PERRL. Moist mucosa. Supple neck. No respiratory distress. Skin warm and dry. Alert and oriented. Normal affect.

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18
Q

Auscultating the heart:

A

regular rate and rhythm. No murmers, rubs, or gallops.

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19
Q

Auscultating the lungs:

A

clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

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20
Q

Palpating the abdomen

A

Soft. Non-tender. Non-distended. No guarding, rebound, or rigidity.

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21
Q

Examining the legs

A

No edema. Distal pulses intact.

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22
Q

Extra Exam: Examines throat

A

looking for pharyngeal erythema or exudates

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23
Q

Extra Exam: examines inner ear

A

looking for TM erythema or bulging

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24
Q

Extra Exam: Auscultates the abdomen

A

looking for Hyperactive/Hypoactive bowel sounds

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25
Extra Exam: Touches the wrists
looking for Radial pulses
26
Extra Exam: Squeezes the calf muscles
looking for calf tenderness
27
Extra Exam: "Pounds" on back
looking for CVA tenderness
28
Normal/Abnormal: No acute distress
Mild/moderate/severe distress due to pain
29
Normal/Abnormal: well developed/well nourished
Cachectic/Emaciated/Malnourished
30
Normal/Abnormal: Alert
Somnolent, Obtunded, Unresponsive
31
Normal/Abnormal: Atraumatic/Normocephalic (AT/NC) Head
Any signs of trauma, sinus tenderness, angioedema
32
Normal/Abnormal: Eyes: PERRL
Anisocoria (unequal pupils)
33
Normal/Abnormal: Extra ocular movements intact (EOMI)
EOM entrapment
34
Normal/Abnormal: Sclera are anicteric
Scleral icterus
35
Normal/Abnormal: normal conjunctiva
pale conjunctiva, conjunctival injection
36
Normal/Abnormal: Eyes: clear anterior chamber
hyphema
37
Normal/Abnormal: Eyes: sharp disc margins
papilledema
38
Normal/Abnormal: Eyes: normal cornea
Corneal abrasion or ulcerations, fluorescein uptake, foreign body
39
Normal/Abnormal: Ears: TMs normal
TM erythema, TM bulging, TM dullness, TM obscured by cerumen (earwax)
40
Normal/Abnormal: Nose: normal nares
Epistaxis, Rhinorrhea, Boggy turminates (swollen inner nose), Septal hematoma
41
Normal/Abnormal: Mouth/Throat: moist mucous membranes
Dry mucous membranes (DMM)
42
Normal/Abnormal: Mouth/Throat: Oropharynx (OP) normal
Pharyngeal erythema, Tonsillar exudate, Tonsillar hypertrophy, Peritonsillar Abscess (PTA)
43
Normal/Abnormal: Mouth/Throat: Normal dentition
Edentulous, Dental caries
44
Normal/Abnormal: Neck: supple
Nuchal rigidity, Meningismus, Limited ROM; Jugular Venous Distension (JVD); Carotid Bruit; Cervical lymphadenopathy (swollen lymph nodes); Thyromegaly; Vertebral point vs. Paraspinal tenderness
45
Normal/Abnormal: CV: Regular rate
Tachycardia (\>100 bpm)/ Bradycardia (\<60 bpm)
46
Normal/Abnormal: CV: regular rhythm
irregularly irregular rhythm
47
Normal/Abnormal: CV: heart sounds normal
Murmer (e.g. 2/6 Systolic Ejection Murmer); Gallop or Rubs, Extrasystoles (extra beats)
48
Normal/Abnormal: Pulses equal and symmetric
unequal pulses
49
Normal/Abnormal: Capillary refill less than 2 seconds
Delayed capillary refill
50
Normal/Abnormal: No respiratory distress
Mild/Moderate/Severe respiratory distress
51
Normal/Abnormal: normal respiratory rate
Tachypnea (sign of respiratory distress)
52
Normal/Abnormal: normal effort
Accessory muscle use (sign of respiratory distress); diminished (quiet) breath sounds
53
Normal/Abnormal: breath sounds equal and clear
Wheezes (inspiratory/expiratory); Rales (crackles); Rhonchi
54
Normal/Abnormal: Abd: soft
rigid (involuntary guarding)
55
Normal/Abnormal: Abd: non-tender
mild/mod/severe tenderness; voluntary guarding
56
Normal/Abnormal: Abd: no peritoneal signs
rebound tenderness, rigidity (involuntary guarding)
57
Normal/Abnormal: Abd: normal bowel sounds
absent/hypoactive/hyperactive bowel sounds; organomegaly (Hepatomegaly or Splenomegaly)
58
Normal/Abnormal: Abd: non-distended
Distended, Positive Murphy's sign, positive McBurney's point tenderness, positive Psoa's sign, positive obturators sign, positive rovsing's sign
59
Normal/Abnormal: Rectal: Heme negative (Guaiac negative)
Heme positive (Guaiac positive)
60
Normal/Abnormal: Brown stool
black/melanotic, bright red, dark red, green, yellow, white; hemorrhoids (internal, external, thrombosed), rectal prolapse
61
Normal/Abnormal: Good rectal tone
Decreased rectal tone (spinal cord injury)
62
Normal/Abnormal: Female Genital: normal external genetalia
adnexal tenderness or mass
63
Normal/Abnormal: female: normal bimanual exam
Cervical motion tenderness (CMT); uterine tenderness
64
Normal/Abnormal: female: normal speculum exam; cervical os is closed; no blood or discharge
cervical os is open; blood in the vaginal vault; malodorous/thick white discharge
65
Normal/Abnormal: male: circumcised/uncircumcised, normal genital exam
testicular tenderness; epididymal tenderness; testicular edema; testicular mass; urethral discharge; inguinal hernia
66
Normal/Abnormal: MS: non-tender
bony tenderness (fracture); soft tissue tenderness (contusion); calf tenderness (DVT)
67
Normal/Abnormal: MS: full ROM
Decreased ROM 2degree pain
68
Normal/Abnormal: MS: distal CSMT intact (circulation, sensory, motor, tendon)
Pulse/sensory/motor deficits/tendon laxity; pitting pedal edema (trace to 4+); palpable cords/Homan's sign (DVT)
69
Normal/Abnormal: back: non-tender thoracic and lumbar spine
Paraspinal tenderness (muscular), Vertebral Point tenderness (spinal injury); CVA tenderness; Midline deformities/step-offs
70
Normal/Abnormal: Skin: warm/normal temp
Cool/hot to touch
71
Normal/Abnormal: skin: dry
diaphoretic
72
Normal/Abnormal: skin: normal color
jaundice, cyanotic, pallor
73
Normal/Abnormal: skin: no rashes
urticaria (hives); petechiae/purpura
74
Normal/Abnormal: skin: no signs of infection
erythema; increased warmth (calor); induration (cellulitis); fluctuance (abscess); purulent drainage; lymphangitis
75
Normal/Abnormal: skin: atraumatic;intact
ecchymosis, contusion, abrasion, laceration, skin tear, avulsion
76
Normal Neuro
Alert/oriented 4 (A&Ox4), non-focal neuro exam sensation intact; motor strength 5/5 and symmetric; DTR's 2+ and equal; CN II-XII intact; normal cerebellar exam; normal gait
77
Abnormal Neuro: LOC
Somnolent, obtunded, unresponsive (to voice or painful stimuli)
78
Abnormal Neuro: Speech
aphasia (expressive or receptive), dysarthria
79
Abnormal Neuro: sensation
hypoesthesia (decreased sensation), numbness (absent sensation)
80
Abnormal Neuro: motor strength
extremity weakness: 0/5 (flaccid) to 4/5 (mildy weak) pronator drift
81
Abnormal Neuro: CN II-XII
visual field loss, unequal pupils (anisocoria), EOM palsy, rightward/leftward gaze, facial asymmetry/droop, decreased gag reflex, tongue deviation
82
Abnormal Neuro: reflexes
Abnormal DTR's, upgoing toes (positive Babinski's)
83
Abnormal Neuro: Cerebellar
dysmetria during finger-to-nose or heel-to-shin, positive Romberg, Vertical nystagmus
84
Abnormal Neuro: gait
ataxia/unsteady gait
85
Neuro strengths and DTRs
Motor strength Exam: 5/5 normal 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 Reflexes Exam: 0 absent 1+ hypoactive 2+ normal 3+ increased 4+ unsustained clonus
86
Normal/Abnormal: Psych: normal affect
flat affect, odd affect, tearful, anxious, depressed, hypomaniac (inappropriately happy/energetic), poor eye contact
87
Normal/Abnormal: psych: normal judgement
suicidal/homicidal (w/or w/o plan) hallucinations (auditory or visual) flight of ideas (loose associations) paranoid
88
Normal/Abnormal: psych: normal insight
denies illness/symptoms non-compliant with treatment
89
Normal/Abnormal: psych: normal speech
tangential speech pressured speech
90
Trauma Exam: Head, Eyes, Ears, Nose, oropharynx
Head: Battle's sign, raccoon eyes, periorbital ecchymosis Eyes: unequal pupils, subconjunctival hemorrhage, hyphema Ears: hemotympanum Nose: nasal bone deformity, epistaxis, septal hematoma oropharynx: malocclusion, dental injury
91
Trauma Exam: Neck, respiratory, abdominal, rectal
Neck: vertebral point tenderness, deformities, step-offs Respiratory: absent breath sounds, splinting, crepitus Rectal: rectal laxity, decreased rectal tone
92
Trauma Exam: MS, Back, skin, neuro
MS: pelvis unstable, bony tenderness, deformities, Back: vertebral point tenderness, deformities, step-offs Skin: ecchymosis, laceration, abrasion, skin tear, avulsion Neuro: Glasgow Coma Scale (GCS \< 15)
93
Code Exam: General, Head, Eyes, Oropharynx
General: unresponsive Head: atraumati Eyes: fixed and dilated Oropharynx: Airway patent, ETT in place
94
Code Exam: Cardio, Respiratory, Abdominal, MS, Skin, Neuro
Cardio: Absent heart sounds, no palpable pulses Respiratory: no spontaneous respirations, equal with controlled ventilation Abdominal: distended MS: no deformities Skin: pallor, cyanotic, mottles Neurological: unresponsive, neurological exam limited due to clinical condition
95
Pediatric Normal Exam: General, head, Eyes, ears, Nose, throat
General: non-toxic, interactive, playful, smiling, crying with tears on exam, quickly consolable head: flat fontanel (if \<8 mo) eyes: PERRL, no scleral icterus ears: nml TMs throat: moist mucous membranes
96
Pediatric Normal Exam: Neck, Cardiac, Respiratory, abdominal, genital, extremities, skin, neuro
Neck: supple, no meningismus cardic: regular rate and rhythm respiratory: no distress, clear and equal abdmonial: soft, no crying or grimacing with palpation genital: nml external, testicals descended extremities: FROM skin: warm, dry, no rash neurological: alert, appropriate for age, moves all 4 extremities (MAE x 4)
97
Pediatric Abnormals: General, head, eyes, ears, throat, neck
general: lethargic, inconsolable, febrile head: sunken fontanel, bulging fontanel eyes: scleral icterus ears: TM erythema, bulging throat: pharyngeal erythema neck: lymphadenopathy
98
Pediatric Abnormals: cardiac, respiratory, abdominal, genital, extremities, skin, neurological
cardiac: murmur, tachycardia respiratory: wheezes, stridor, retractions, nasal flaring abdominal: crying with abdominal palpation genital: erythema extremeties: ecchymoses in various stages of healing skin: rash (diaper rash, eczema) neurological: post-ictal, somnolent

Scribe America ED (13 decks)

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