Physical Exam Findings Review

  1. Do any patient complaints belong in the physical exam? No
  2. What does PERRL stand for?
    Pupils are equal round and reactive to light
  3. What does AT/NC mean?
    Atraumatic/Normocephalic
  4. What does NAD stand for?
    No acute distress/disease
  5. If a patient has pale conjunctiva, what does that indicate?
    Anemia
  6. What is scleral icterus, and what does it indicate?
    Yellowing of the eyes, indicates liver failure
  7. Name an instrument a physician may use to closely investigate the eyes?
    Slit lamp, Woods lamp, Ophthalmoscope (aka fundoscopic exam)
  8. In which body system would you document “TM erythema and bulging”?
    Ears
  9. What is the medical term for a nostril?
    Naris (both nostrils is nares)
  10. To describe a “runny nose” what word would the doctor use?
    Rhinorrhea
  11. What would dry mucous membranes indicate?
    Dehydration
  12. 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
  13. 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
  14. Name the rhythm that the physician would hear if the patient was in Afib.
    Irregularly irregular rhythm
  15. 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+
  16. Name two “Peritoneal signs” in the abdominal exam?
    Guarding, rebound tenderness, rigidity
  17. What abdominal exam sign is indicative of Cholecystitis?
    Murphy’s Sign
  18. 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
  19. Which of these findings is NOT a peritoneal sign: Guarding, Rebound, Tenderness, Rigidity
    Tenderness
  20. What would a “Guaiac positive” stool sample diagnose?
    GI Bleed
  21. What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician?
    Female Chaperone present
  22. What is bony tenderness a sign of?
    Bone deformity, fracture, or injury
  23. What is CVA tenderness?
    Flank tenderness (costovertebral angle tenderness). Tenderness over the kidney(s)
  24. What is fluctuance a sign of?
    Abscess
  25. What is the difference between a laceration and abrasion?
    • Laceration – incision in the skin that typically need sutures.
    • Abrasion- scrape of the skin
  26. What procedure is associated with a laceration, but not an abrasion?
    Laceration Repair, Sutures
  27. What does A&Ox3 mean?
    Alert and oriented to person, place, time
  28. What section of the neurological exam would you document “Normal Finger-Nose-Finger test” and “Normal Heel-to-Shin”?
    Cerebellar/ Coordination
  29. What does DTR stand for?
    Deep tendon reflex
  30. Point to the general area of your body that Cranial Nerves (CN) control.
    Face
  31. In the neurological exam, what does “Normal gait” mean?
    Walking normally
  32. In the psychiatric exam, what do SI and HI stand for?
    Suicidal and Homicidal ideations
  33. Is the Glascow Coma Scale (GCS) associated with Trauma pts or Medical patients?
    Trauma
  34. Would you document “RUE strength 3/5” under the “Neurological” or “Extremities” section of the exam?
    Neuro
  35. What would you guess “TTP” means? (e.g. “TTP in the RUQ”)
    Tender to palpation
  36. 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!
  37. Spell the medical term for “Hives” (allergic reaction rash)
    Urticaria
  38. What is the medical term for “Swollen lymph nodes?”
    Lymphadenopathy
  39. If you document “There is right pronator drift” in the neurological exam, can you also document “No focal neurological deficits”?
    No, contradiction
  40. 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
Author
st2478
ID
343325
Card Set
Physical Exam Findings Review
Description
course 4 - PE
Updated