The Physical Exam and Common Medical Conditions + Surgeries

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226 Terms

1

somnolent

drowsy or sleepy disposition

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2

cachectic/emaciated

physically wasting (extremely thin)

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3

morbidly obese

large body mass index (BMI)

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4

nontoxic appearing

well-appearing patient in minimal distress (often used to describe well-appearing pediatric patients)

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5

normocephalic

normal appearance and size of the head

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6

atraumatic

no signs of trauma present

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7

cyanosis

bluish discoloration of the skin due to a lack of oxygen

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8

pallor

an unhealthy paleness of the skin

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9

erythema

superficial reddening of the skin

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10

jaundice

yellowing of skin due to abnormal bilirubin build-up

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11

abrasion

superficial wound to the top most layer of the skin

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12

contusion

a region of skin in which blood capillaries are ruptured; aka bruise

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13

ecchymosis

an area of ruptured blood vessels similar to a contusion; aka bruise

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14

laceration

a cut in the skin

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15

puncture

a small hole in the skin

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16

wheal

round, localized area of edema on the skin

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17

wheal-and-flare

(a reaction) rash or hives (irregular, blanch raised areas with redness)

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18

urticaria

hives or wheals which are either redder or paler than the surrounding area and are often accompanied by itching

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19

maculopapular

rash or hives (flat red area covered with small confluent bumps)

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20

pustules

small collection of pus under the skin

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21

bullae

fluid-filled blisters

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22

petechiae

a small round flat dark-red spot caused by bleeding into the skin or beneath the mucus membrane

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23

purpura

purple spots or blotches (don’t turn white when pressed)

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24

induration

a hardened area of normally soft tissue

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25

fluctuance

movable and compressible

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26

hemangloma

a benign tumor consisting of blood vessels

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27

cornea

the transparent coat of the eyeball that covers the iris and pupil; lets light into the eye

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28

sclera

the dense fibrous opaque outer coat enclosing the eyeball - except the part covered by the cornea

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29

conjunctiva

white area of the eyes

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30

icterus

yellowing of sclera due to bilirubin build-up (often seen with jaundice)

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31

subconjunctival hemorrhage

bright red patches in conjunctiva of eyes due to ruptured blood vessels

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32

extraocular movements intact (eomi)

appropriate function of the extraocular muscles, tested with “follow my finger”

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33

pupils equal, round and reactive to light (perrl)

normal evaluation of the size, shape of the pupils and their reaction to light

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34

papilledema

swelling of the optic disk due to an increase in intracranial pressure

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35

fundi sharp

non-swollen optic nerve on exam of fundus (back of eye) with ophthalamoscope

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36

visual acuity

acuteness/sharpness of vision as measured by the eye chart

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37

eyelid eversion

flipping the eyelid for exam underneath the eyelid

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38

normal palpebral conjunctiva

eyelid membrane is clear

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39

exophthalmos

bulging of eyes out of socket

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40

nystagmus

involuntary rapid eye movements - often reported as horizontal, vertical, or rotary

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41

erythema of the external canal

redness of outer ear canal

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42

cerumen impaction

excessive earwax

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43

tympanic membrane (tm)

eardrum

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44

erythematous tm

red color of the tm

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45

bulging tm

protruding/outward curvature of the tm

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46

retracted tm

inward curve of the tm

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47

poor light reflect

cone of light does not reflect on tm

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48

unable to visualize landmarks

provider cannot see landmarks behind tm

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49

hemotympanum

blood on the tm

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50

mastoid tenderness

tenderness over mastoid bone (located posterior to ear)

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51

clear rhinorrhea

clear nasal drainage

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52

septal deviation

displacement of nasal septum

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53

septal hematoma

bruising or bleeding in the nasal septum

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54

dry mucous membranes

dry mouth

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55

tongue laceration

cut on the tongue

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56

no signs of oral trauma

no cuts/chipped teeth/etc.

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57

dental caries

cavity

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58

poor dentition

bad teeth

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59

pericoronitis

infection of the gums

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60

parotid mass

enlargement of the parotid gland

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61

trismus

inability to open mouth normally due to spasm of the jaw muscles

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62

normal jaw approximation

normal jaw alignment

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63

malocclusion

misalignment of the teeth when mouth closed

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64

uvula midline

no deviation of the uvula to one side or another

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65

pharyngeal erythema

redness of the throat

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66

pharyngeal exudate

pus seen on the posterior throat

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67

peritonsilar abscess

deep abscess adjacent to infected tonsils (collection of pus/swelling which is usually only visible if drained)

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68

carotid bruit

abnormal flow of blood through the carotid artery

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69

jugular vein distension (jvd)

swelling of the jugular vein (usually seen in heart failure patients)

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70

cervical vertebral tenderness

pain along cervical spine

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71

no step-offs or crepitus

no misalignment of the vertebral bodies (spinous processes) as the spine is palpated

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72

anterior cervical lymphadenopathy

swollen lymph nodes under jaw and along anterior neck area

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73

trachea midline

no deviation of trachea from its usual location

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74

meningismus

patient has neck stiffness, photophobia, and headache which may suggest meningitis

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75

nuchal rigidity

neck stiffness with neck movement

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76

bradycardia

slow heart rate; less than 60 beats per minute

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77

tachycardia

fast heart rate; greater than 100 beats per minute

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78

murmur

an abnormal sound heard when listening to the heart

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79

systolic murmur

heart murmur heard during systole (active pumping)

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80

diastolic murmur

heart murmur heard during diastole (rest/active filling)

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81

distant heart sounds

faint-sounding heart beats

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82

rubs

coarse sounds produced when the heart “rubs” on inflamed pericardium (heart tissue) during contractions

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83

gallops

extra/abnormal heart sounds (should only hear 2 distinct sounds, but you hear 3 or 4 sounds)

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84

bradypnea

abnormally slow breathing

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85

tachypnea

abnormally rapid breathing

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86

apnea

temporary absence or cessation of breathing

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87

prolonged inspiratory expiratory phase

increased time between inspiratory and expiratory phases

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88

rhonchi

a whistling or snoring sound hear on auscultation of the chest when air channels are partially obstructed; plural of rhochus

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89

wheezes

difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways

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90

stridor

harsh or high-pitched respiratory sound, caused by an obstruction of the air passages

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91

intercostal retractions

use of intercostal muscles with breathing (indicates severe respiratory distress/work of breathing) - sunken intercostal muscles (can see ribs)

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92

accessory muscle use

using extra muscles to breath (you can usually see an emphasis on use of diaphragm and intercostal muscles)

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93

costovertebral angle tenderness (cvat)

angle in back where kidneys are (HCP taps); left, right, and bilateral - if pain then possible kidney pathology

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94

paraspinal muscle tenderness

tenderness in muscles adjacent to spine

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95

midline tenderness

tenderness directly over spine

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96

no step-offs

no misalignment of thoracic/lumbar spine

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97

straight leg raise

if pain, indicative of herniated disk

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98

saddle anesthesia

loss of sensation around buttocks area

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99

distension

bloating

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100

gravid

pregnant

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