physical exam

Anatomical Position

Reference position for the human body, standing erect with arms at sides and palms facing forward.

erythema

redness

anisocoria

unequal pupil sizes/dilations

ecchymosis

bruise from broken blood vessel

scleral icterus

jaundiced eyes

COPD

chronic obstructive pulmonary disease

trendelenburg

position in which patient lays flat on stretcher with legs elevated above their head

Fowlers Position

Inclined position achieved by raising the head of the bed to relieve muscle strain or aid breathing.

Palpation

Examination technique using hands to feel for tenderness or abnormalities in the body.

Auscultation

Listening with a stethoscope to sounds within the body like heartbeats or breathing.

Symmetry

Equality on both sides of the body, such as in strength or appearance.

Generalized Appearance

Initial impression of a patient's well-being based on visual observation of appearance, behavior, and mobility.

Skin Turgor

Skin's ability to return to normal after being pinched, indicating hydration status.

Abscess

Localized collection of pus surrounded by inflamed tissue.

Cyanosis

Bluish skin discoloration due to poor oxygenation of the blood.

Lymphangitis

Inflammation of lymphatic vessels characterized by red streaks on the skin.

Urticaria

Raised, reddened, and itchy skin area due to allergic reaction, also known as hives.

Concussion

Temporary loss of brain function following a violent blow, shaking, or spinning.

Epidural Hematoma

Accumulation of blood between the skull and dura mater in the brain.

Intracerebral Hemorrhage

Accumulation of blood within the brain tissue, often due to trauma or aneurysm rupture.

Subarachnoid hemorrhage

Accumulation of blood into the subarachnoid space.

Subdural Hematoma

Accumulation of blood between the dura and arachnoid mater.

Migraine

Episodic attacks of moderate to severe headaches associated with symptoms like nausea, blurred vision, and sensitivity to light, sound, or head movement.

Sclera

White of the eye.

Retina

Innermost, light-sensitive layer of the eye.

Fundus

Inside portion of the eye containing the optic nerve, veins, and arteries.

Cornea

Transparent part covering the iris and pupil.

Iris

Muscle/colored portion of the eye.

Pupil

Opening of the iris.

Conjunctivae

Thin covering of the sclera.

Hyphema

Hemorrhage in the anterior chamber of the eye.

Intraocular pressure (IOP)

Pressure created by fluids in the eye; can cause damage or glaucoma.

Ptosis

Drooping of the eyelid.

Proptosis

Bulging of the eyes.

PERRL

Pupils Equal, Round, and Reactive to Light.

PERRLA

Pupils Equal, Round, and Reactive to Light and Accommodation.

Scleral injection

Redness of the sclera.

Visual acuities

Measure of the resolving power of the eyes.

Cataract

Clouding of the lens of the eye.

Conjunctivitis

Inflammation of the conjunctivae making it red

Otitis Externa

Infection or inflammation of the external auditory canal.

Labyrinthitis

Inflammation of the inner ear causing vertigo and balance issues.

Epistaxis

Nosebleed.

Rhinitis

Inflammation of the nasal lining.

Deviated septum

Leaning of the septum causing nostril blockage.

Dental Caries

Tooth decay causing severe pain.

Malocclusion

Misalignment of teeth in the upper and lower jaw.

Stridor

High-pitched sound on inhalation due to larynx or trachea inflammation.

Thrush

White patches in the mouth caused by fungus.

Stoma

Opening from an organ to the outside of the body.

Uvular edema

Swelling of the uvula; associated with angioedema, urticaria, and anaphylaxis

Aphonia

Complete loss of voice due to disease of voice producing structures

Epiglottitis

Inflammation of the epiglottis that can result in a life-threatening airway obstruction

Laryngitis

Inflammation of the larynx, causing hoarse voice or loss of voice due to irritation to the vocal folds

Odynophagia

Painful swallowing

Pharyngitis

Inflammation of the pharynx; commonly known as a "sore throat"

Tonsillitis

Inflammation of the tonsils

Upper Respiratory Infection (URI)

Infection (typically viral) of the mouth, nose, throat, larynx, and trachea; referred to as a "cold"

Trachea

Windpipe, tube passing from larynx to bronchi

Lymph nodes

Organs within the lymphatic system; important for immune system functioning

Thyroid

Endocrine gland in the neck

Carotid arteries

Arteries located in the front of the neck below the angle of the jaw

Goiter/thyromegaly

Enlarged thyroid

Jugular venous distention (JVD)

Caused by back-up of fluid in the jugular vein; common in CHF or severe chest trauma

Lymphadenopathy

Abnormal size or consistency of lymph nodes, commonly associated with infection

Meningeal Sign (Brudzinski’s)

Symptom of meningitis; elicited by forced flexion of the neck causing reflex flexion of the hips

Nuchal rigidity

Resistance to forward flexion of the neck; may indicate possible meningitis

Symmetry

Noting any potential deformities or abnormalities

Supple

Bends and moves easily

Tenderness

Midline tenderness along the vertebrae; concerning for possible vertebrae fracture

Pulmonary congestion/edema

Abnormal accumulation of fluid in the lungs, often seen in congestive heart failure (CHF).

Pulmonary Embolus (PE)

A blood clot that has traveled to the lungs and obstructed blood flow.

Risk factors for blood clots (PE and DVT)

Factors include prolonged immobility, recent surgery, fractures, history of cancer, birth control pills, pregnancy, obesity, smoking, and history of diseases like CVA, heart disease, or HTN.

Atria

Upper two chambers of the heart.

Ventricle

Lower two chambers of the heart.

Aorta

Main artery of the heart pumping oxygenated blood to the circulatory system.

Pulmonary Artery

Artery carrying blood to the lungs for oxygenation.

Pulmonary Vein

Blood vessel carrying oxygenated blood from the lungs back to the heart.

Heart Valves

Structures allowing blood flow in one direction through the heart (tricuspid, pulmonary, mitral, aortic).

Perfusion

Normal oxygenation of organs and tissues in the body.

Rhythm

Refers to the regularity of heartbeats, categorized as regular, regularly irregular, or irregularly irregular.

Capillary refill

Test of circulation where the nail regains color within 2 seconds after pressure is released.

Edema

Swelling due to excess fluid accumulation in tissues, characterized as pitting or non-pitting.

Angioedema

Swelling in the lower layer of skin and mucous membranes, often due to allergic reactions.

Venous insufficiency

Decrease in venous function leading to symptoms like swelling, pain, and skin irritation.

Pulses

Rhythmic throbbing felt in arteries, assessed in various locations like apical, carotid, femoral, brachial, radial, etc.

Acute Coronary Syndrome (ACS)

Broad term for conditions due to reduced blood flow to the heart, such as myocardial infarction (MI).

Aneurysm

Weakening of a vessel wall causing bulging.

Arrhythmia

Abnormal heart rhythm.

Coronary Artery Disease (CAD)

Accumulation of plaques in coronary arteries, leading to reduced blood flow to the heart.

Deep Vein Thrombosis (DVT)

Blood clot in a deep vein, often in the lower extremities.

Myocardial Infarction (MI)

Heart attack due to reduced blood flow to the heart muscle.

Palpitations

Sensation of rapid or irregular heartbeats.

Supraventricular Tachycardia (SVT)

Abnormally fast arrhythmia originating in the atria of the heart.

Ventricular Arrhythmias

Arrhythmias originating in the ventricles of the heart, including ventricular fibrillation and tachycardia.

Hypertension in Adults

Blood pressure readings ≥ 140 mmHg systolic or ≥ 90 mmHg diastolic.

Normal Respiratory Rate in Adults

Breathing rate between 12 to 20 breaths per minute.

Normal Blood Pressure in Children (1-8 years)

Ranges from 80 to 110 mmHg.

Abdominal Quadrants

Divided into LUQ, LLQ, RUQ, and RLQ for organ localization.