MEDICAL SCRIBE PHYSICAL EXAM
(NORMAL TO ABNORMAL) QUESTIONS
AND ANSWERS
General/constitutional normal - Answer-no acute distress (NAD)
well developed, well nourished
alert
General/constitutional abnormal - Answer-mild/moderate/severe distress (due to pain)
cachectic/emaciated/malnourished
somnolent, obtunded, unresponsive
Head normal - Answer-atraumatic/ normocephalic (AT/NC)
Head abnormal - Answer-any signs of trauma
sinus tenderness
angioedema
eyes normal - Answer-pupils equal, round, reactive to light (PEERL)
extraoccular movements intact (EOMI)
sclerae are anicteric
normal conjunctiva
eyes abnormal - Answer-Anisocoria (unequal pupils)
EOM entrapment
Scleral icterus
Pale conjunctiva (Anemia)
Conjunctiva; injection (conjunctivitis)
ears normal - Answer-tympanic membranes (TMs) normal
ears abnormal - Answer-TM erythema
TM bulging
TM dullness
TM obscured by cerumen
Nose normal - Answer-normal nares
singular- naris
plural- nares
nose abnormal - Answer-epistaxis
rhinorrhea
boggy turbinates (swollen inner nose)
, septal hematoma
mouth and throat normal - Answer-moist mucous membrane
oropharynx (OP) normal
normal dentition
mouth and throat abnormal - Answer-dry mucous membrane (DMM)
pharyngeal erythema, tonsillar exudate, tonsillar hypertrophy
edentulous, dental caries
signs of PTA (peritonsillar abscess)
uvula shift
tonsillar asymmetry
neck and cervical spine normal - Answer-supple
neck and cervical spine abnormal - Answer-nuchal rigidity, meningismus, limited ROM
thyromegaly
jugular venous distension (JVD)
carotid bruit
cervical lymphadenopathy (swollen lymph nodes)
vertebral points vs. paraspinal tenderness
cardiovascular normal - Answer-regular rate
regular rhythm
heart sounds normal
abnormal cardiovascular - Answer-tachycardia (>100bpm)
bradycardia (<60 bpm)
irregularly irregular rhythm
murmur
gallop
rub
extrasystoles (extra beats)
cv contradiction regular rate - Answer-tachycardia (>100bpm)
bradycardia (<60 bpm)
cv contradiction regular rhythm - Answer-irregularly irregular rhythm
cv contradiction heard sounds normal - Answer-irregularly irregular rhythm
murmur
gallop
rub
extrasystoles (extra beats)
perfusion - Answer-radial pulse
(NORMAL TO ABNORMAL) QUESTIONS
AND ANSWERS
General/constitutional normal - Answer-no acute distress (NAD)
well developed, well nourished
alert
General/constitutional abnormal - Answer-mild/moderate/severe distress (due to pain)
cachectic/emaciated/malnourished
somnolent, obtunded, unresponsive
Head normal - Answer-atraumatic/ normocephalic (AT/NC)
Head abnormal - Answer-any signs of trauma
sinus tenderness
angioedema
eyes normal - Answer-pupils equal, round, reactive to light (PEERL)
extraoccular movements intact (EOMI)
sclerae are anicteric
normal conjunctiva
eyes abnormal - Answer-Anisocoria (unequal pupils)
EOM entrapment
Scleral icterus
Pale conjunctiva (Anemia)
Conjunctiva; injection (conjunctivitis)
ears normal - Answer-tympanic membranes (TMs) normal
ears abnormal - Answer-TM erythema
TM bulging
TM dullness
TM obscured by cerumen
Nose normal - Answer-normal nares
singular- naris
plural- nares
nose abnormal - Answer-epistaxis
rhinorrhea
boggy turbinates (swollen inner nose)
, septal hematoma
mouth and throat normal - Answer-moist mucous membrane
oropharynx (OP) normal
normal dentition
mouth and throat abnormal - Answer-dry mucous membrane (DMM)
pharyngeal erythema, tonsillar exudate, tonsillar hypertrophy
edentulous, dental caries
signs of PTA (peritonsillar abscess)
uvula shift
tonsillar asymmetry
neck and cervical spine normal - Answer-supple
neck and cervical spine abnormal - Answer-nuchal rigidity, meningismus, limited ROM
thyromegaly
jugular venous distension (JVD)
carotid bruit
cervical lymphadenopathy (swollen lymph nodes)
vertebral points vs. paraspinal tenderness
cardiovascular normal - Answer-regular rate
regular rhythm
heart sounds normal
abnormal cardiovascular - Answer-tachycardia (>100bpm)
bradycardia (<60 bpm)
irregularly irregular rhythm
murmur
gallop
rub
extrasystoles (extra beats)
cv contradiction regular rate - Answer-tachycardia (>100bpm)
bradycardia (<60 bpm)
cv contradiction regular rhythm - Answer-irregularly irregular rhythm
cv contradiction heard sounds normal - Answer-irregularly irregular rhythm
murmur
gallop
rub
extrasystoles (extra beats)
perfusion - Answer-radial pulse
