PE note per section Flashcards

(93 cards)

1
Q

General Survey

A
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Mental status

A
Speech
language
mood
thought content
perceptions
insight
judgement
orientation
attention
memory
information and vocabulary
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pulse

A

unusually fast or slow

rhythm regular or irregular

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

respirations

A

observing rate
rhythm
depth
effort of breathing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

skin

A
color
temperature
texture
turgor
mobility
moisture
rashes
lesions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

hands and nails

A
cyanosis
clubbing
nail deformities
tremors
erythema or pallor (palmar creases of the hands)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

skull

A

general size

contour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

scalp

A

scaliness
nei
lesions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

hair

A

quantity
distribution
pattern of loss
dandruff

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

face, nose, mouth

A
symmetry
contours
involuntary movements
edema
lesions
masses and expression
pathognomonic facies?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

TMJ

A

swelling

redness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

palpate hair and scalp

A
hair texture
quantity and distribution
scalp and skull for deformities
tenderness
lesions
scaliness
lumps
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

TMJ

A

ROM
pain
crepitus
clicking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

neck

A

symmetry
masses
scars
tracheal position

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

thyroid

A

movement of masses
masses
thyroid enlargement

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

trachea

A

deviation from midline

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Cervical lymph nodes: locations

A
occipital
posterior auricular
preauricular
posterior cervical
superficial cervical
suprclavicular 
deep cervical
tonsillar
submandibular
submental
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Cervical lymph nodes…note:

A
size
shape
mobility
consistency
lymphatic enlargement
tenderness 
induration
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

thyroid

A
size
shape
consistency
tenderness
masses or nodules
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

eyebrows

A

quanitity
distribution
scaliness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

eyelids

A
edema
color
lesions
direction of eyelashes 
adequacy with which they close
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

lacrimal gland and sac

A

swelling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

conjunctiva and sclera

A

color
vascular pattern
nodules
swelling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

iris and pupils

A

size
shape
symmetry

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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