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31 Cards in this Set
- Front
- Back
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MOI |
Mechanism of injury |
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Past SHx indicative of CAD |
CABG, Cardiac stents, angioplasty |
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Benign exam |
Constitutional- well developed, nourished, no acute distress Eyes- PERRL, EOMI ENT- moist mucous membranes Neck- supple (no lymphadenopathy) Cardiovascular- regular rate and rhythm, no murmurs, rubs or gallops, distal pulse intact Respiratory- no distress, clear to auscultation, no wheezes, rales or rhonchi abdominal- soft, non-tender, no guarding, rebound or rigidity extremities- no edema, full ROM Skin- warm, dry neuro- alert, oriented psychiatric- normal |
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General/constitutional |
Normal: NAD, well-developed/nourished, alert abnormal : distress, cachectic, emaciated, malnourished, somnolent, obtunded, unresponsive |
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Head |
nml: atraumatic/normocephalic abnormal: sinus tenderness, angioedema |
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eyes |
nml: PERRL, EOMI, sclera are anicteric, normal conjunctiva abnml: anisocoria (unequal pupils, scleral icterus, pale conjunctiva (conjunctival injection) |
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Detailed eye exam |
nml: clear anterior chamber, sharp disc margins, normal cornea abnml: retinal detachment, papilledema, hyphema, corneal abrasion or ulcerations, fluorescein uptake |
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ears |
nml: TM's normal abnml: TM erythema, bulging, dullness, obscured by cerumen |
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Nose |
nml: nml nares abnml: epistaxis, rhinorrhea, septal hematoma, boggy turbinates |
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mouth/throat |
nml: moist mucous membranes, oropharynx normal abnml: dry mucous membranes, dental caries, endentulous, pharyngeal erythema, tonsillar exudate, tonsillar hypertrophy, peritonsillar abscess |
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Neck and cervical spine |
nml: supple abnml: JVD, carotid bruit, cervical lymphadenopathy, vertebral point vs. paraspinal (around the spine) tenderness, thyromegaly |
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cardiovascular |
nml: regular rate & rhythm, heart sounds nml abnml: tachy/bradycardia, IIR, murmur, extrasystoles, pleural rub, gallop |
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Perfusion |
radial, carotid, femoral, dorsalis pedis, posterior tibialis nml: pulses equal and symmetric, capillary refill less than 2 sec abnml: delayed, 0(absent), 1(barely palpable), 2(easily palpable, nml), 3(full), 4(bounding/aneurysmal) |
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Pulmonary |
nml: no respiratory distress, clear to auscultation (CTA) bilaterally abnml: respiratory distress, tachypnea, wheezes, rales, rhonchi |
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abdominal |
nml: soft and non-tender abnml: tenderness to palpation, voluntary guarding, rebound tenderness, rigidity (involuntary guarding)...all signs of surgical abdomen |
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detailed abdominal |
nml: nml bowel sounds, no organomegaly, no mass abnml: absent, hypo/hyperactive bowel sounds, organomegaly (hepato/splenomegaly), distended, murphy's sign( RUQ cholecystitis), McBurney's point tenderness (RLQ appendicitis) |
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Rectal |
nml: nml rectal tone, heme negative abnml: heme positive (Guaiac +), abnormal stool color, hemorrhoids, rectal prolapse, decreased rectal tone |
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female gentials |
nml: nml external genitalia, normal bimanual exam, normal speculum exam, cervical O's closed, no blood or discharge abnml: sores, lesions, rashes, cervical motion tenderness, adnexal tenderness, cervical o's open, blood in vaginal vault, malodorous, thick white discharge |
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male genitals |
nml: nml abnml: testicular, epididymal tenderness, testicular edema/mass, urethral discharge, inguinal hernia, indwelling catheter |
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musculoskeletal/extremities |
nml: non-tender, full rom distal csmt (circulation, sensory, motor, tendon) intact, no edema, no calf tenderness abnml: bony tenderness (fx), soft tissue tenderness (contusion), calf tenderness (DVT), decreased ROM, PSM deficits, tendon laxity, pitting pedal edema, palpable cords, Homan's sign (DVT) |
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Back |
nml: nontender thoracic spine/lumbar abnml: CVA tenderness, paraspinal tenderness (muscle), vertebral point tenderness (Spinal cord), midline deformities |
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skin (integumentary) |
nml: warm, dry abnml: cool/hot, diaphoretic, jaundic, cyanotic, pallor, urticaria (hives), petechiae/purpura |
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skin infection |
nml: no erythema, warmth or discharge abnml: erythema, calor, induration (cellulitis), fluctuance (abscess), purulent drainage, lymphangitis |
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skin trauma |
nml: atraumatic, intact abnml: ecchymosis, contusion, abrasion, laceration, tear, avulsion |
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neuro |
nml: alert, oriented (person, place, time), nml speech, non-focal neuro exam abnml: somnolent, disoriented, aphasia, dysarthria |
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motor strength (neuro) |
pronator drift, upper/lower extremity strength |
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neuro (cranial nerve) |
nml: visual field intact, PERRL, EOMI, tongue midline, normal gag, facial symmetry, sensation intact, equal shoulder shrug abnml: visual field loss, anisocoria, EOM palsy, tongue deviation, decreased gag reflex, facial droop (ptosis), hypoesthesia (numbness), unequal shoulder shrug |
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chest pain- benign exam ddx: MI, PE, dissection, PNA, PTX |
neck- no JVD cardiovascular- regular rate and rhythm, no murmurs, rubs, or gallops respiratory- no distress, breaths clear and equal, no wheezes, rales or rhonchi extremities - no pedal edema, non-tender calves skin- no diaphoresis |
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SOB -benign ddx: PE, CHF, MI, PNA, COPD, Asthma, pleural effusion |
general: nad, afebrile eyes: no pale conjunctiva ENT: airway patent Neck: No JVD Cardivascular: regular rate and rhythm, symmetric pulses Respiratory: No respiratory distress, good air movement, breath sounds clear and equal, no wheezes, rales or rhonchi extremities: no pedal edema, non-tender calves skin: no diaphoresis neuro: alert, oriented x3 |
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abd pain -benign ddx: appendicitis, cholecystitis, GI bleed, AAA, SBO, pancreatitis, liver failure |
General: afebrile eyes: no scleral ictus, no pale conjunctiva, ENT: moist mucous membranes abd: soft, non-tender, no guarding, rebound or rigidity, no distension, active bowel sounds, no hepato-spleno megaly, no midline pulsatile masses skin: no jaundice |
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Headache- benign ddx:CVA, TIA, CA, meningitis, sinusitis, subarachnoid hemorrhage |
general: afebrile eyes: PERRL, EOMI, ENT: no sinus tendernessl, no temporal tenderness neck: supple, painless ROM, no nuchal rigidity, no meningismus skin: no petechia, no purpura neuro: alert and oriented x3, nml speech motor strength 5/5 symmetric, sensation intact, Finger nose finger normal, normal cerebellar exam |
