The Physical Exam and Common Medical Conditions + Surgeries

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226 Terms

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somnolent
drowsy or sleepy disposition
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cachectic/emaciated
physically wasting (extremely thin)
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morbidly obese
large body mass index (BMI)
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nontoxic appearing
well-appearing patient in minimal distress (often used to describe well-appearing pediatric patients)
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normocephalic
normal appearance and size of the head
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atraumatic
no signs of trauma present
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cyanosis
bluish discoloration of the skin due to a lack of oxygen
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pallor
an unhealthy paleness of the skin
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erythema
superficial reddening of the skin
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jaundice
yellowing of skin due to abnormal bilirubin build-up
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abrasion
superficial wound to the top most layer of the skin
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contusion
a region of skin in which blood capillaries are ruptured; aka bruise
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ecchymosis
an area of ruptured blood vessels similar to a contusion; aka bruise
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laceration
a cut in the skin
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puncture
a small hole in the skin
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wheal
round, localized area of edema on the skin
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wheal-and-flare
(a reaction) rash or hives (irregular, blanch raised areas with redness)
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urticaria
hives or wheals which are either redder or paler than the surrounding area and are often accompanied by itching
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maculopapular
rash or hives (flat red area covered with small confluent bumps)
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pustules
small collection of pus under the skin
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bullae
fluid-filled blisters
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petechiae
a small round flat dark-red spot caused by bleeding into the skin or beneath the mucus membrane
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purpura
purple spots or blotches (don’t turn white when pressed)
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induration
a hardened area of normally soft tissue
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fluctuance
movable and compressible
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hemangloma
a benign tumor consisting of blood vessels
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cornea
the transparent coat of the eyeball that covers the iris and pupil; lets light into the eye
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sclera
the dense fibrous opaque outer coat enclosing the eyeball - except the part covered by the cornea
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conjunctiva
white area of the eyes
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icterus
yellowing of sclera due to bilirubin build-up (often seen with jaundice)
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subconjunctival hemorrhage
bright red patches in conjunctiva of eyes due to ruptured blood vessels
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extraocular movements intact (eomi)
appropriate function of the extraocular muscles, tested with “follow my finger”
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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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papilledema
swelling of the optic disk due to an increase in intracranial pressure
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fundi sharp
non-swollen optic nerve on exam of fundus (back of eye) with ophthalamoscope
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visual acuity
acuteness/sharpness of vision as measured by the eye chart
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eyelid eversion
flipping the eyelid for exam underneath the eyelid
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normal palpebral conjunctiva
eyelid membrane is clear
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exophthalmos
bulging of eyes out of socket
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nystagmus
involuntary rapid eye movements - often reported as horizontal, vertical, or rotary
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erythema of the external canal
redness of outer ear canal
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cerumen impaction
excessive earwax
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tympanic membrane (tm)
eardrum
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erythematous tm
red color of the tm
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bulging tm
protruding/outward curvature of the tm
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retracted tm
inward curve of the tm
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poor light reflect
cone of light does not reflect on tm
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unable to visualize landmarks
provider cannot see landmarks behind tm
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hemotympanum
blood on the tm
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mastoid tenderness
tenderness over mastoid bone (located posterior to ear)
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clear rhinorrhea
clear nasal drainage
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septal deviation
displacement of nasal septum
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septal hematoma
bruising or bleeding in the nasal septum
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dry mucous membranes
dry mouth
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tongue laceration
cut on the tongue
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no signs of oral trauma
no cuts/chipped teeth/etc.
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dental caries
cavity
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poor dentition
bad teeth
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pericoronitis
infection of the gums
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parotid mass
enlargement of the parotid gland
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trismus
inability to open mouth normally due to spasm of the jaw muscles
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normal jaw approximation
normal jaw alignment
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malocclusion
misalignment of the teeth when mouth closed
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uvula midline
no deviation of the uvula to one side or another
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pharyngeal erythema
redness of the throat
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pharyngeal exudate
pus seen on the posterior throat
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peritonsilar abscess
deep abscess adjacent to infected tonsils (collection of pus/swelling which is usually only visible if drained)
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carotid bruit
abnormal flow of blood through the carotid artery
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jugular vein distension (jvd)
swelling of the jugular vein (usually seen in heart failure patients)
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cervical vertebral tenderness
pain along cervical spine
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no step-offs or crepitus
no misalignment of the vertebral bodies (spinous processes) as the spine is palpated
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anterior cervical lymphadenopathy
swollen lymph nodes under jaw and along anterior neck area
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trachea midline
no deviation of trachea from its usual location
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meningismus
patient has neck stiffness, photophobia, and headache which may suggest meningitis
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nuchal rigidity
neck stiffness with neck movement
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bradycardia
slow heart rate; less than 60 beats per minute
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tachycardia
fast heart rate; greater than 100 beats per minute
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murmur
an abnormal sound heard when listening to the heart
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systolic murmur
heart murmur heard during systole (active pumping)
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diastolic murmur
heart murmur heard during diastole (rest/active filling)
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distant heart sounds
faint-sounding heart beats
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rubs
coarse sounds produced when the heart “rubs” on inflamed pericardium (heart tissue) during contractions
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gallops
extra/abnormal heart sounds (should only hear 2 distinct sounds, but you hear 3 or 4 sounds)
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bradypnea
abnormally slow breathing
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tachypnea
abnormally rapid breathing
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apnea
temporary absence or cessation of breathing
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prolonged inspiratory expiratory phase
increased time between inspiratory and expiratory phases
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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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wheezes
difficult breathing with a whistling sound resulting from narrowing of the lumen of the respiratory passageways
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stridor
harsh or high-pitched respiratory sound, caused by an obstruction of the air passages
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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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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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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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paraspinal muscle tenderness
tenderness in muscles adjacent to spine
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midline tenderness
tenderness directly over spine
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no step-offs
no misalignment of thoracic/lumbar spine
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straight leg raise
if pain, indicative of herniated disk
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saddle anesthesia
loss of sensation around buttocks area
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distension
bloating
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gravid
pregnant