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Scribe America ED > Physical Exam > Flashcards

Physical Exam Flashcards

1
Q

Benign

A

Not harmful

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2
Q

Anatomical Position

A

A frame of reference used to describe anatomy and movement.

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3
Q

Tenderness

A

Pain felt upon palpation.

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4
Q

Icterus

A

Yellowing, also known as jaundice.

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5
Q

Purulent

A

Pus-like

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6
Q

Erythema

A

Redness

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7
Q

Organomegaly

A

Organ enlargement

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8
Q

Perfusion

A

The flow of blood through the body’s blood vessels.

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9
Q

Affect

A

The patient’s immediate expression of emotion.

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10
Q

Consolable

A

Able to be comforted.

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11
Q

GCS

A

Glasgow Coma Exam – used to assess the level of consciousness in trauma pts.

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12
Q

General/Constitutional – Normal Physical Exam

A
  • No Acute Distress (NAD) – comfortable appearing.
  • Well-developed, Well-nourished.
  • Alert
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13
Q

General/Constitutional – Abnormal Physical Exam

A
  • Mild/Moderate/Severe Distress (due to pain).
  • Cachectic/Emaciated/Malnourished
  • Somnolent, Obtunded, Unresponsive.
  • C-Collar, Backboard, Oxygenation (91% 10L O2 NC)

Somnolent and Obtunded = drowsy but responsive.

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14
Q

Head – Normal Physical Exam

A

Atraumatic/Normocephalic (AT/NC)

“a” – without

-cephalic – head

Peri- – around

Periorbital – around the eyes.

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15
Q

Head – Abnormal Physical Exam

A
  • Any signs of trauma
  • Sinus tenderness
  • Angioedema
  • Allergic reaction

Angioedema – swelling of the eyes, lips, throat, or tongue.

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16
Q

Eyes – Normal Physical Exam

A
  • Pupils Equal, Round, Reactive to Light (PERRL)
  • Extraocular Movements Intact (EOMI)
  • Sclerae Anicteric
  • Normal Conjunctiva
  • Normal Cornea (External Eye – with Wood’s lamp or Fluorescein)

Sclera – the white part of the eyes.

Anicteric – without yellowing.

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17
Q

Eyes – Abnormal Physical Exam

A
  • Anisocoria (unequal pupils)
  • EOM entrapment
  • Scleral Icterus (Liver Failure)
  • Pale conjunctiva (Anemia)
  • Conjunctival injection (Conjunctivitis)
  • Fluorescein uptake (Corneal Abrasion or Ulcerations)

! Do NOT use erythema for the eyes, document conjunctival injection, not erythema (the eyes are the exception to erythema).

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18
Q

Ears/Throat – Normal Physical Exam

A
  • Tympanic Membranes (TMs) Normal
  • Moist Mucous Membranes
  • Oropharynx (OP) Normal
  • Normal dentition
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19
Q

Ears/Throat – Abnormal Physical Exam

A
  • TM erythema, bulging, or dullness

*Sometimes the doctor cannot visualize the TM because it’s obstructed by cerumen (earwax)

  • Dry mucous membranes (DMM)
  • Pharyngeal erythema
  • Tonsillar exudate
  • Tonsillar hypertrophy (enlargement/overgrowth)
  • Edentulous (toothlessness)
  • Dental caries (cavities)
  • Uvular Shift
  • Tonsillar Asymmetry

Uvular Shift and Tonsillar Asymmetry are signs of Peritonsillar Abscess

Tonsillar exudate – fluid secreted by the tonsils in response to infection or inflammation.

! When the doctor checks the TM, look out for OM.

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20
Q

Neck and Cervical Spine – Normal Physical Exam

A
  • Nontender Cervical Spine (C-Spine)
  • Supple (free movement of a body part)
  • Normal appearance and normal ROM (range of motion).
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21
Q

Neck and Cervical Spine – Abnormal Physical Exam

A
  • Vertebral Point (Midline) vs. Paraspinal Tenderness
  • Nuchal rigidity, Meningismus, Limited ROM
  • Carotid bruit
  • Cervical lymphadenopathy (swollen lymph nodes)
  • Jugular Venous Distension (JVD)
  • Thyromegaly

! Avoid a contradiction if the patient has a C-collar on – cannot document full ROM.

Vertebral Tenderness – Possible spinal fracture.

22
Q

Cardiovascular (CV) – Normal Physical Exam

A
  • Regular Rate
  • Regular Rhythm
  • Heart sounds normal

Rate – The number of times the ventricle contract per minute.
Rhythm – A measurement of whether the heart beats at regular intervals (lub-dub noise).

23
Q

Cardiovascular (CV) – Abnormal Physical Exam

A
  • Tachycardia(>100 bpm) / Bradycardia (<60 bpm)
  • Irregularly Irregular Rhythm
  • Murmur (e.g. 2/6 Systolic Ejection Murmur)
  • Gallop or Rubs
  • Extrasystoles (extra beats)

Murmur – Abnormal heart sounds due to malfunctioning heart valve, rated on a 1-6 scale.

Gallop – Three or four sounds, resembling a horse’s gallop.

Rub – A scratching, grating sound of the heart, concerning for pericarditis (the heart is rubbing the sac surrounding it).

24
Q

Perfusion – Physical Exam

A

The flow of blood through the body’s blood vessels.

  • Radial Pulse
  • Carotid Pulse
  • Femoral Pulse
  • Dorsalis Pedis (DP) Pulse
  • Posterior Tibial (PT) Pulse
25
Perfusion – Documentation
Pulses Equal and Symmetric, Capillary Refill less than 2 seconds Delayed capillary refill 0 = Absent 1+ = Barely palpable 2+ = Easily palpable (Normal) 3+ = Full 4+ = Bounding/Aneurysmal ! You must document the strength and the location of the pulses on the physical exam. Capillary refill – a measure of time it takes for the distal capillary bed to regain color after pressure has been applied to cause blanching. A normal capillary refill in less than 2 seconds.
26
Pulmonary – Normal Physical Exam
* No respiratory distress * Normal respiratory rate * Normal effort * Breath Sounds Clear and Equal
27
Pulmonary – Abnormal Physical Exam
* Mild/Moderate/Severe respiratory distress * Tachypnea (sign of respiratory distress) * Accessory muscle use (sign of respiratory distress) * Diminished (quiet) breath sounds * Wheezes (inspiratory or expiratory) * Rales (Crackles) * Rhonchi
28
Pulmonary – Contradictions
**Normal Finding** * No respiratory distress * Normal effort **Contradictory Abnormal Finding** * Mild/Moderate/Severe Respiratory Distress * Tachypnea * Accessory muscle use **Normal Finding** * Clear to auscultation bilaterally (CTAB) * Normal breath sounds **Contradictory Abnormal Finding** * Diminished breath sounds * Inspiratory/expiratory * Wheezes (Insp. Exp.) – High pitches noise (Asthma) * Rales (Crackles) – Liquid/Fluid (CHF) * Rhonchi – Junky noise (PNA and COPD)
29
Abdominal – Normal Physical Exam
* Soft * Non-tender * No peritoneal signs
30
Abdominal – Abnormal Physical Exam
* Rigid (involuntary guarding) * Mild/Mod/Severe tenderness * Rebound Tenderness * Rigidity (Involuntary Guarding) * Voluntary Guarding Tenderness – pain increases with pressure during palpation. Rebound – pain increases upon releasing pressure. G.R.R – Guarding (tensing up – voluntary or involuntary), Rebound, Rigidity. (G.R.R signs are peritoneal signs – signs of a surgical abdomen). ! Don't forget to document the location.
31
Abdominal Detailed
32
Rectal – Normal Physical Exam ! Document "Chaperone Present"
* Heme Negative * Brown Stool * Normal Rectal Tone **Chaperone** – Clinical healthcare worker that is the same sex as the patient.
33
Rectal – Abnormal Physical Exam
* Heme positive (Guaiac positive) * ANY Abnormal stool color: Black/Melanotic, Red, Yellow, White, Bright Red * Decreased rectal tone (spinal cord injury) * Hemorrhoids (Internal, External, Thrombosed)
34
Female Genital – Normal Physical Exam ! Document "Female Chaperone Present"
* Normal External Genitalia * Normal Bimanual Exam * Normal Speculum Exam * Cervical os is closed * No blood or discharge
35
Female Genital – Abnormal Physical Exam
* Sores, Lesions, Rashes * Cervical motion tenderness (CMT) * Uterine tenderness * Adnexal tenderness (Ovaries) * Cervical Os is open * Blood in the vaginal vault * Malodorous/thick white discharge
36
Male Genital – Normal Physical Exam ! Document "Male Chaperone Present"
* Circumcised OR Uncircumcised * Testicular Exam WNL
37
Male Genital – Abnormal Physical Exam
* Testicular Tenderness, Edema, or Mass * Epididymal Tenderness * Urethral Discharge * Inguinal Hernia * Indwelling Catheter
38
Musculoskeletal (Extremities) – Normal Physical Exam
* Non-tender * Full ROM (FROM) * Distal CSMT (Circulation, Sensory, Motor, Tendon) intact * No Edema * No calf tenderness
39
Musculoskeletal (Extremities) – Abnormal Physical Exam
* Bony tenderness (Fracture) * Soft tissue tenderness (Contusion) * Decreased ROM 2° pain * Pulse/Sensory/Motor deficits Tendon Laxity * Pitting pedal edema (Trace to 4+) * Calf tenderness (DVT) * Palpable cords/Homan's sign (DVT)
40
Musculoskeletal (Back) – Normal Physical Exam
* Nontender Thoracic (T-Spine) and Lumbar Spine (L-Spine)
41
Musculoskeletal (Back) – Abnormal Physical Exam
* Costovertebral Angle (CA) Tenderness * Paraspinal Tenderness (Muscle Pain) and/or Vertebral Point Tenderness (Spinal Cord Injury) * Midline Deformities/ Step-Offs Para- – next to.
42
Integumentary/Skin – Normal Physical Exam
* Warm (Normal Temperature) * Dry * Normal color * No rashes * Atraumatic * No erythema, warmth, or drainage
43
Integumentary/Skin – Abnormal Physical Exam
* Cool to touch; Hot to touch * Diaphoretic – Pale appearing * Jaundice (Yellow), Cyanotic (Blue), Pallor * Any rash. * Examples: Urticaria (Hives), Petechiae/Purpura. * Any sign of trauma. * Examples: Ecchymosis, Contusion, Abrasion, Laceration, Skin Tear, Avulsion * Any sign of infection. * Examples: Erythema, Increased warmth (Calor), Induration (Cellulitis), Fluctuance (Abscess), Purulent Drainage, Lymphangitis (Spreading infection) Maculopapular rash – red bumps that are flat and raised.
44
Neurological – Normal Physical Exam (Nonfocal Neuro Exam)
* Alert * Oriented x4 * Normal Speech * Is the face symmetrical? * Cranial Nerves 2-12 Intact * Nonfocal Neuro Exam
45
Neurological – Contradictory Abnormal Physical Exam (Nonfocal Neuro Exam)
* Somnolent, Obtunded, Unresponsive * Disoriented to (person, place, time, or situation) * Aphasia (Expressive or Receptive) – due to signal from the brain not received properly. * Slurred speech * Dysarthria (inability to speak due to motor malfunctions or neural weakness). * Cranial Nerves – Provider will specify. * Examples of cranial nerve deficits may be Visual field loss, Unequal pupils, Facial droop, EOM palsy, or facial Hypoesthesia. * Paraesthesia = Abnormal sensation/Pins and Needles. Nonfocal (not localized – general neuro exam) Neuro Exam – Any abnormal findings * *Aphasia** – think language problems. * *Dysarthria** – think speech problems due to motor/muscles. * *Expressive aphasia** – "can't find the right words" (Broca's). * *Receptive aphasia** – The right words are being replaced with the wrong output.
46
Neurological – Normal Physical Exam (Motor and Sensation)
* Motor Strength 5/5 and Symmetric * Sensation Intact 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 (Effort against force/gravity)
47
Neurological – Abnormal Physical Exam (Motor and Sensation)
* Extremity Weakness (see chart below) * Pronator Drift * Hypoesthesia (decreased sensation) * Numbness (absent sensation) * Paraesthesia – Abnormal sensation (usually pins and needles)
48
Neurological – Reflexes
**Deep Tendon Reflexes (DTRs)** 0 – Absent 1+ – Hypoactive 2+ – Normal 3+ – Increased 4+ – Unsustained clonus
49
Neurological – Normal Physical Exam (Cerebellar Exam "Coordination")
* Normal gait * No nystagmus * Normal finger-to-nose * Normal heel-to-shin * Negative Romberg's
50
Neurological – Abnormal Physical Exam (Cerebellar Exam "Coordination")
* Ataxia (uncoordinated), Antalgic (walking to avoid pain) * Nystagmus * Dysmetria * Positive Romberg

Scribe America ED (13 decks)

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