-
Do any patient complaints belong in the physical exam? No
-
What does PERRL stand for?
Pupils are equal round and reactive to light
-
What does AT/NC mean?
Atraumatic/Normocephalic
-
What does NAD stand for?
No acute distress/disease
-
If a patient has pale conjunctiva, what does that indicate?
Anemia
-
What is scleral icterus, and what does it indicate?
Yellowing of the eyes, indicates liver failure
-
Name an instrument a physician may use to closely investigate the eyes?
Slit lamp, Woods lamp, Ophthalmoscope (aka fundoscopic exam)
-
In which body system would you document “TM erythema and bulging”?
Ears
-
What is the medical term for a nostril?
Naris (both nostrils is nares)
-
To describe a “runny nose” what word would the doctor use?
Rhinorrhea
-
What would dry mucous membranes indicate?
Dehydration
-
Why is midline bony tenderness “worse” than paraspinal tenderness?
- Bony tenderness (aka vertebral point tenderness) points towards a spinal fracture and
- therefore concern for spinal cord injury.
- Paraspinal tenderness points toward a muscle sprain or strain
-
If you saw “RRR” written in the cardiac exam, what do you think it might mean? (Hint: It is a normal cardiac finding)
Regular Rate and Rhythm
-
Name the rhythm that the physician would hear if the patient was in Afib.
Irregularly irregular rhythm
-
If the physician checks the pulse on the right wrist and says “The pulses are fine”, what would you document in the physical exam:
Right radial pulse is 2+
-
Name two “Peritoneal signs” in the abdominal exam?
Guarding, rebound tenderness, rigidity
-
What abdominal exam sign is indicative of Cholecystitis?
Murphy’s Sign
-
If the doctor takes 1 finger and presses in a specific spot in the RLQ, what
- is the name of the finding they are investigating?
- McBurney’s point tenderness
-
Which of these findings is NOT a peritoneal sign: Guarding, Rebound, Tenderness, Rigidity
Tenderness
-
What would a “Guaiac positive” stool sample diagnose?
GI Bleed
-
What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician?
Female Chaperone present
-
What is bony tenderness a sign of?
Bone deformity, fracture, or injury
-
What is CVA tenderness?
Flank tenderness (costovertebral angle tenderness). Tenderness over the kidney(s)
-
What is fluctuance a sign of?
Abscess
-
What is the difference between a laceration and abrasion?
- Laceration – incision in the skin that typically need sutures.
- Abrasion- scrape of the skin
-
What procedure is associated with a laceration, but not an abrasion?
Laceration Repair, Sutures
-
What does A&Ox3 mean?
Alert and oriented to person, place, time
-
What section of the neurological exam would you document “Normal Finger-Nose-Finger test” and “Normal Heel-to-Shin”?
Cerebellar/ Coordination
-
What does DTR stand for?
Deep tendon reflex
-
Point to the general area of your body that Cranial Nerves (CN) control.
Face
-
In the neurological exam, what does “Normal gait” mean?
Walking normally
-
In the psychiatric exam, what do SI and HI stand for?
Suicidal and Homicidal ideations
-
Is the Glascow Coma Scale (GCS) associated with Trauma pts or Medical patients?
Trauma
-
Would you document “RUE strength 3/5” under the “Neurological” or “Extremities” section of the exam?
Neuro
-
What would you guess “TTP” means? (e.g. “TTP in the RUQ”)
Tender to palpation
-
A mother states her child has been extremely tired and drowsy recently; based on that, can you document “Lethargic” in the child’s physical exam?
No!
-
Spell the medical term for “Hives” (allergic reaction rash)
Urticaria
-
What is the medical term for “Swollen lymph nodes?”
Lymphadenopathy
-
If you document “There is right pronator drift” in the neurological exam, can you also document “No focal neurological deficits”?
No, contradiction
-
If you documented “NAD” in the constitutional section, would you be contradicting yourself if you wrote “There is mild respiratory distress” in the pulmonary exam?
Yes
|
|