Physical Exam Flashcards

Question

Perfusion – Documentation

Answer 1

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.

Answer 2

* No respiratory distress * Normal respiratory rate * Normal effort * Breath Sounds Clear and Equal

Answer 3

* 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

Answer 4

**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)

Answer 5

* Soft * Non-tender * No peritoneal signs

Answer 6

* 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.

Answer 7

* Heme Negative * Brown Stool * Normal Rectal Tone **Chaperone** – Clinical healthcare worker that is the same sex as the patient.

Answer 8

* 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)

Answer 9

* Normal External Genitalia * Normal Bimanual Exam * Normal Speculum Exam * Cervical os is closed * No blood or discharge

Answer 10

* 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

Answer 11

* Circumcised OR Uncircumcised * Testicular Exam WNL

Answer 12

* Testicular Tenderness, Edema, or Mass * Epididymal Tenderness * Urethral Discharge * Inguinal Hernia * Indwelling Catheter

Answer 13

* Non-tender * Full ROM (FROM) * Distal CSMT (Circulation, Sensory, Motor, Tendon) intact * No Edema * No calf tenderness

Answer 14

* 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)

Answer 15

* Nontender Thoracic (T-Spine) and Lumbar Spine (L-Spine)

Answer 16

* Costovertebral Angle (CA) Tenderness * Paraspinal Tenderness (Muscle Pain) and/or Vertebral Point Tenderness (Spinal Cord Injury) * Midline Deformities/ Step-Offs Para- – next to.

Answer 17

* Warm (Normal Temperature) * Dry * Normal color * No rashes * Atraumatic * No erythema, warmth, or drainage

Answer 18

* 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.

Answer 19

* Alert * Oriented x4 * Normal Speech * Is the face symmetrical? * Cranial Nerves 2-12 Intact * Nonfocal Neuro Exam

Answer 20

* 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.

Answer 21

* 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)

Answer 22

* Extremity Weakness (see chart below) * Pronator Drift * Hypoesthesia (decreased sensation) * Numbness (absent sensation) * Paraesthesia – Abnormal sensation (usually pins and needles)

Answer 23

**Deep Tendon Reflexes (DTRs)** 0 – Absent 1+ – Hypoactive 2+ – Normal 3+ – Increased 4+ – Unsustained clonus

Answer 24

* Normal gait * No nystagmus * Normal finger-to-nose * Normal heel-to-shin * Negative Romberg's

Answer 25

* Ataxia (uncoordinated), Antalgic (walking to avoid pain) * Nystagmus * Dysmetria * Positive Romberg

Physical Exam Flashcards

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