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Flashcards in PE note per section Deck (93):
1

General Survey

body habitus
nutritional state
sexual development
presenting appearance
hygiene (odors body and breath)
stated vs apparent age
demeanor
facial affect or expression
posture
gait
level of conciousness
apparent pain
signs of distress

2

Mental status

Speech
language
mood
thought content
perceptions
insight
judgement
orientation
attention
memory
information and vocabulary

3

Pulse

unusually fast or slow
rhythm regular or irregular

4

respirations

observing rate
rhythm
depth
effort of breathing

5

skin

color
temperature
texture
turgor
mobility
moisture
rashes
lesions

6

hands and nails

cyanosis
clubbing
nail deformities
tremors
erythema or pallor (palmar creases of the hands)

7

skull

general size
contour

8

scalp

scaliness
nei
lesions

9

hair

quantity
distribution
pattern of loss
dandruff

10

face, nose, mouth

symmetry
contours
involuntary movements
edema
lesions
masses and expression
pathognomonic facies?

11

TMJ

swelling
redness

12

palpate hair and scalp

hair texture
quantity and distribution
scalp and skull for deformities
tenderness
lesions
scaliness
lumps

13

TMJ

ROM
pain
crepitus
clicking

14

neck

symmetry
masses
scars
tracheal position

15

thyroid

movement of masses
masses
thyroid enlargement

16

trachea

deviation from midline

17

Cervical lymph nodes: locations

occipital
posterior auricular
preauricular
posterior cervical
superficial cervical
suprclavicular
deep cervical
tonsillar
submandibular
submental

18

Cervical lymph nodes...note:

size
shape
mobility
consistency
lymphatic enlargement
tenderness
induration

19

thyroid

size
shape
consistency
tenderness
masses or nodules

20

eyebrows

quanitity
distribution
scaliness

21

eyelids

edema
color
lesions
direction of eyelashes
adequacy with which they close

22

lacrimal gland and sac

swelling

23

conjunctiva and sclera

color
vascular pattern
nodules
swelling

24

iris and pupils

size
shape
symmetry

25

note depression of lower lids: sclera and palpebral conjunctive

icterus
conjunctival inflammation
pterygiums
pingueculae
xantelasmas
ireis lesions
pupillary inequality
nystagmus
strabismus

26

pupillary reflexes

direct and consensual light reflexes

27

accommodative reflex

convergence of the eyes
pupillary constriction

28

Extraocular Muscles

EOM paralysis
disconjugate gaze
nystagmus
lid lag

29

visual fields

gross visual field defects

30

fundoscopy of eyes: inpect

red reflex
disc
retina-arterioles
veins
fovea
macula
vitreous
lens

31

Fundoscopy of eyes: Note

opacities in the ocular media
disc cupping
vessel narrowing
a-V nicking
pilledema
retinal exudates
retinal hemorrhages
macular changes
disc sharpness and color

32

nose inspection

septal deviation
septal perforations
mucosal inflammation
nasal discharge
lesions

33

nose palpation

tenderness
patency of each nostril
frontal sinus tenderness
maxillary sinus tenderness

34

Mouth inspection

lips
buccal mucosa
gums
teeth
tongue
palate
floor of the mouth
posterior pharynx
tonsillar pillars and tonsils

35

Mouth inspection (overall note)

REMOVE DENTURES:
color
inflammation
exudate
swelling
moisture
lesions
ulcers
dental arries
tonsilar enlargement
breath odor

36

lips

moisture
color
lumps
ulcers
cracking
scaliness

37

buccal mucosa

color
ulcers
white patches
nodules

38

gums

swelling
ulceration

39

teeth

carries and looseness

40

tongue

erythema
nodules
ulcerations

41

palate, floor of mouth, posterior pharynx, tonsillar pillars and tonsils

exudate
swelling
ulceration
tonsilar enlargement

42

ears: auricles

deformities
keloids
lesions
lumps
discarge from EAC

43

ear: palpate note

tenderness or masses

44

ears otoscopic exam: inspect

tympanic membrane and EAC

45

ears otoscopic exam: note

discharge
foreign bodies
erythema
edema
color and contour of eardrum
tympanic scarring or perforation
TM bulging or retraction
air-fluid levels
masses
bleeding
vascular lesions

46

axillary and epitrochlear nodes

lymphatic size
consistency
enlargement or tenderness

47

Chest inspection

chest symmetry
expansion or deformities
respiratory pattern and distress
intercostal or supraclavicular retractions
abdominal vs thoracic breathing

48

thoracic expansion

asymmetric chest expansion or splinting of respirations

49

tactile fremitus

increased or decreased fremitus

50

Percuss chess

unexpected dullness or hyperresonance

51

Auscultate chest

pitch
intensity
loudness
quality of breath sounds
Note:
increased, decreased or abnormal breath sounds
crackles
wheezes
rhonci
rubs

52

cardiovacular perecordium inspection

apical impulse or PMI if visible
any abnormal precordial motion including lifts or heaves

53

carotid pulse

amplitude
timing
contour of pulse wave or thrills

54

apical impulse

abnormal motion including lifts, heaves or thrills
abnormal pulsations
location
size
force of the apical impulse

55

caroids

carotid bruits

56

Note precordium:auscultate

regular or irregular rhythm

57

Note on 1st and 2nd heat sounds

loudness
splitting
splitting? affected by respiration or position
S3 or S4 present?

58

Murmur

timing (systolic vs diastolic)
location (best heard)
Grade (1-6)
Radiation
Pitch
Quality

59

S3 and S4 notes

low pitched diastolic rumble of mitral or tricuspid stenosis or an S3 and/or S4

60

murmur of aortic regurgitation

high pitched early diastolic murmur of aortic insufficiency

61

Peripheral pulses

rate
rhythm
quality

62

PV lower extremities

skin temperature
edema
decreased hair growth
lesions
ulcerations
varicocities

63

inspection of abdomen

contour (flat, scaphoid, rounded, protruberant)
symmetry
angiomata
ecchymoses
striae
rashes
lesions
scars
visible peristalsis
arterial pulsations
distended abdominal wall veins

64

Auscultation of abdomen

bowel sounds (increased, decreased, or normal)

65

auscultation abdomen: vascuar

any bruits

66

Percussion of abdomen

unusual tympani or dullness

67

splenic percussion

change in percussion note from resonant/tympanic to dullness on inspiration=spenic enlargement

68

Palpation of abdomen

tenderness
organomegally
masses

69

Ingunal nodes

enlargement
induration
tenderness

70

CVA tenderness

significant tenderness

71

musculoskeletal

edema
deformity
color
hypertrophy
abdnormal joint positioning
atrophy
alignment
unusual body contours or prominence

72

suculoskeletal palpation

edema
deformity
temperature
hypertrophy
atrophy
crepitus
clicking
locking
instability
laxity
unusual bony contours or prominences
joint positioning

73

musculoskeletal ROM

decreased ROM or pain

74

Neurological: mental status exam

overall presentation and appearance
level of consciousness
behavior
mood
affect
language
orientation
attention
memory
abstract thinking

75

CN1

anosmia

76

CN V

assemmetry of masseter muscle contraction

77

CN VII

asymetry of facial movement

78

CN IX and X

if soft palate fails to rise on one side
hoarseness or dysphonia?

79

CN XI

strength and contraction of muscle

80

CN XII

deviation
asymmetry
fasciculation
atrophy

81

Motor inspection

muscle atrophy or bulk
tremors
tics
fasciculations

82

Motor muscle tone

spasticity
rigidity
decreased muscle tone

83

Motor muscle strenth

Weakness in:

84

alternative screening tests: Motor muscle strength

UE:
handgrip strength

LE:
Observing patient rising from chair
walking on toes
walking on heals

85

Cerebellar function: coordination

tremors or cerebellar disease

86

Cerebellar function: Gait

ataxia
limp
weakness
orther abnormal gait

87

heal-toe walk

ataxia

88

cerebellar function: stance

romberg test
difficulty maintaining balance with eyes open or closed

89

Cerebellar function: pronator drift

pronation of one forearm
downward drift of arm with flexion of fingers and elbow

tap of arm after 20 seconds: smooth return of arms to horizontal position

90

Sensory: Crude touch

sensory deficits

91

tactile discrimination

Stereognosis
Graphesthesia

92

reflexes

increased, decreased, absent reflexes

93

Ankle clonus

sustain clonus