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20 Cards in this Set

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9 General Appearance ABNL
1. concious = lethargic
2. distress = clutching chest
3. state of health = chronically ill
4. skin color/obvious lesions = cyanosis, bruising
5. sex dev = no facial hair on male > 25 y/o
6. posture/gait/motor activity = leaning forward, ataxic, tremor
7. dress, grooming, personal hygiene = copper bracelet, grown out nailpolish, unkempt appearance
8. odors of body/breath = acetone
9. facial expression = immobile
6 ABNL skin
1. color = erythmatous
2. moisture = xerosis
3. temperature = cold
4. texture = rough
5. mobility/tugor = slow
6. lesion = brown nevi, upper R arm, unilateral
Head
-quantity, distribution, texture, pattern of loss, nits/dandruff of hair
-facies of head
Eyebrow
-quantity
-distribution
-scaliness
Eyelids
-position in relation to eye
-width of palpebral fissure
-edema
-color
-lesions
-condition & direction of eyelashes
-adequacy of eyelid closure
-lacrimal gland and sac for swelling
Inner eye appearance
-color of sclera and conjunctiva
-vascular pattern
-nodules
-swelling
Cornea, Lens and Iris
-opacity of cornea and lens
-clear marking of iris
pupils
-shape
-symmetry
-size
-red reflex
Inner eye
-clarity of optic disc
-yellow-orange to creamy pink
-size of physiologic cup
-Arteries and Veins of retina
Auricle
-deformities
-lumps
-skin lesions
Ear Canal
-discharge
-FB
-redness
Tympanic membrane
-color
-contour
-cone of light
-handle and short process of malleous
-pars flaccida and tensa
Nasal mucosa and turbinates
-color
-swelling
-bleeding
-exudates
Nasal septum
-deviation
-perforation
-inflammation
-abnormalities (polyp/ulcer)
Lips
-color
-moisture
-lumps
-ulcers
-cracking
-scaliness
Oral mucosa
-color
-ulcers
-white patches
-nodules
Interior inspection of the mouth
-soft palate
-ant and post pillars
-uvula
-tonsils
-pharynx
Neck
-symmetry
-masses
-scars
-enlargement of submandibular and parotid gland
-visable lymph nodes
ABNL lymph node
-size
-shape
-delimitation
-mobility
-consistency
-tenderness
Nails
-color
-shape
-texture
-lesions
-capillary refill