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14 Cards in this Set

  • Front
  • Back
General appearance
General appearance
LOC
Affect
Hygiene
Distress
Posture
Body structure
Piercings/Tattoos
___________________________________
Spine configuration
Spine, Shoulder, Hip ROM
Gait: normal, heels, toes, heels to toes
Romberg test
heel-to-shin
Head and Face
Head and Face
Head size, contour, shape, and tenderness
Hair distribution, texture, color, and pests
Lesions and flaking
Symmetry
Involuntary movements
TMJ
Temporal pulses
___________________________________
CN V: TMJ + cotton to 4 areas
CN VII: raise eyebrows, puff out cheeks, smile, frown, close eyes against resistance
Ears
Ears
Inspect for placement, shape, discharge
Palpate pinna, tragus, mastoid process
___________________________________
Finger rub
Otoscopic exam: external canal, tympanic membrane, landmarks
Eyes
Eyes
symmetry, shape
eyebrows, eyelids, eyelashes
conjunctiva, sclera, cornea, iris
___________________________________
Eye alignment (Hirschberg)
CN III: EOM (6 cardinal fields)
CN III: PERRLA: pupil size, shape, equality, response to light direct+ consensual, accommodation (near+far)
Red reflex
Nose
Nose
Alignment
discharge
mucosa
Nares patent (sniff one side, then the other)
___________________________________
CN I: Identifies odor
Mouth and throat
Mouth and throat
Inspect: lips, teeth, oral mucosa, gingiva, pharynx, tonsils
___________________________________
CN IX and CN X: "say Ah" uvula rises midline = gag reflex
swallow with mouth closed
CN XII: tongue protrudes midline
Neck
Neck
contour
tracheal position
thyroid size
palpate carotid arteries
auscultate for bruit
palpate 12 cervical lymph nodes
___________________________________
ROM
JVD
CN XI: turn head against resistance, shrug shoulders against resistance
Anterior Lungs
Anterior Lungs
Respiratory rate, rhythm, and effort
Skin color
Shape/configuration of the chest
Palpate for tenderness and masses
Skin turgor
Quality of lung sounds
Adventitious sounds
Egophony
Heart
Heart
Inspect for apical pulse and other pulsations
Palpate for PMI, heaves, thrills, and lifts
Auscultate with bell+diaphragm for APETM
Heart rate and rhythm
S1 and S2
Adventitious sounds
S3 and S4
murmurs, rubs
Pulse deficit
Lateral and Posterior Chest
Lateral and Posterior Chest
Inspect shape, configuration, and skin condition
Symmetry
Tenderness
___________________________________
Expansion
Tactile fremitus
CVA tenderness
Quality of lung sounds
Adventitious sounds
Egophony
Abdomen
Abdomen
Contour
Symmetry
Hair distribution
Scars
Skin color, condition, venous pattern
Umbilicus
Aortic pulsation
Movement (peristaltic / respiratory)
___________________________________
Auscultate 4 areas bowel tones and their quality
Auscultate for bruits (aortic, renal, iliac, femoral)
Palpate for guarding, masses, tenderness
Rebound tenderness
Referred pain
Upper extremities
Upper extremities
Skin color and temperature
Hair distribution
Nail beds for color
Nails for shape and clubbing
Capillary refill
Muscle groups for size and symmetry
Muscle tone (spasticity/flaccidity)
Symmetry and size of joints
Tenderness of joints
___________________________________
Brachial and radial pulses
ROM/crepitus of elbow, wrist, and fingers
Muscle strength in shoulders, arms, and hands
Gross motor coordination: Flap hands on thigh
Fine motor coordination: finger to thumb
DTRs: biceps, triceps, brachioradialis
Sensory to cotton
Sharp/dull
Lower extremities
Lower extremities
Skin color and temperature
Hair distribution
Edema
Nail beds for color, shape, and consistency
Capillary refill
Muscle groups for size and symmetry
Muscle tone (spasticity/flaccidity)
Symmetry and size of joints
___________________________________
Pulses: femoral, popliteal, posterior tibialis, dorsalis pedis
ROM/crepitus of knees and ankles
Muscle strength in hips, knees, ankles
Joints for tenderness
Gross motor coordination: Heel-to-shin
DTRs: patellar and achilles
Babinski reflex
Sensation to cotton
Sharp/dull
Monofilament
Vibratory sense
Breast self-exam
Breast self-exam
Instruct that the self-exam needs to be done every month at the same time, and that it's very important to note early signs of cancer
Inspect contour and symmetry
skin changes, lesions, or dimpling
Motility with position changes
Palpate for masses
Axillary lymph nodes
Nipple discharge