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223 Cards in this Set
- Front
- Back
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nursing process
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assessment, diagnosis, outcome identification, planning, implementation, evaluation
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nursing diagnosis evaluates..
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the response of the whole person to actual or potential health problems
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follow-up database
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monitors progress
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emergency database
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rapid collection of information during life saving matters
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episodic database
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used for limited time or short-term problem
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complete database
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complete health history and full exam
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cooperative play
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children playing and interacting while doing it
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delayed imitation
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a child can witness an event, forma mental picture of it, and later imitate it
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mental representations
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piaget; age 2, infant can think of an external even without experiencing it
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object permanence
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piaget; concept during infancy that objects and people continue to exist after out of sight
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prehension
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act of grasping w/fingers
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symbolic function
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piaget; children learn to use symbols to represent people, objects, events
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telegraphic speech
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by age of 3 or 4, begin to put together sentences with only essential words
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transductive reasoning
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child's thinking that when 2 events happen at the same time that one caused the other
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heritage consistency
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degree to which a person's life relfects his/her traditional heritage
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Title VI of Civil Rights Act
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people with limited english proficiency cannot be denied service from a health care agency
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animism
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imagining inanimate objects have human characteristics
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genogram
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complete family history
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mental assessment 4 headings
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ABCT- appearance, behavior, cognition, thought process
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test for cognitive function; ability to lay new memories
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4 unrelated words test
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mini-mental state exam
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assesses cognitive function and detects dementia
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behavioral checklist
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completed by a parent to assess mental status of a child 7-11 years old
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flat affect
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lack of emotional response
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anxiety
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apprehension from anticipation of unknown danger
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rage
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loss of control
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lability
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rapid shift of emotions
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auscultatory gap
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brief period of time when korotkoff's sounds disappear- common w/HTN
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4 general survey observations
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appearance, body structure, mobility, behavior
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MAP=
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diastolic + 1/3pulse press.
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transduction
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first phase of nociception; painful stimulus changed into action potential
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trasmission
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second phase of nociception; pain impulse moves from the spinal cord to the brain
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anergy
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absent immune reaction to injection of antigens
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mid arm muscle area (MAMA)
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more sensitive indicator of lean body mass
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annular
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circualr shape to a skin lesion
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bulla
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elevated cavity containing free fluid >1cm diameter
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excoriation
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self-inflicted abrasion on skin due to scratching
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keloid
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hypertrophic scar, raised
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maceration
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softening of tissue by soaking
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macule
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flat skin lesion w/only color change
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nevus
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mole
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nodule
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elevated skin lesion >1cm diameter
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papule
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palpable skin lesion of <1 cm
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plaque
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skin lesion which many papules coalesce
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pustule
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elevated cavity containing thick turbid fluid
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vesicle
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elevated cavity containing free fluid <1cm
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wheal
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raised red skin lesion due to interstitial fluid
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zosteriform
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linear shape of skin lesion along a nerve route
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early jaundice is first assessed in these 2 places
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sclera, hard palate
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skin temp most accurately felt by
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dorsal hand
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where/why test for skin turgor
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anterior chest under clavicle, determine dehydration
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normal angle of nail bed
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160 degrees
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torticollis
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head titl d/t shortening or spasm of one sternomastoid muscle
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normal, palpable lymph nodes
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mobile, soft, nontender
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s/s of migraine h/a
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throbbing, unilateral pain, N/V, with photophobia
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anisocoria
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unequal pupil size
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arcus senilis
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gray-white arc around iris, common w/aging
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argyll robertson pupil
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pupil nonreactive to light, but constricts w/accommodation
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chalazion
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nodule on eyelid
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norm cup-disc ratio
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<.5
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ectropion
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lower eyelid loose, rolling outward
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exophthalmos
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protruding eyeballs
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fovea
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area of best vision
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hordeolum
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stye; painful postule of infected hair follicle
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myopia
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nearsighted
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OD
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right eye
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OS
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left eye
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strabismus
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crossed eyed
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palpebral fissure
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open space b/t eyelids
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annulus
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rim encircling the eardrum
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atresia
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absence/closure of ear canal
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organ of corti
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sensory organ of hearing
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otalgia
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pain in ear
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otorrhea
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discharge from the ear
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tinnitus
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ringing of the ear
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umbo
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knob of malleus that shows through the tympanic membrane
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direction pulling pinna to see ear of child
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directly down (<3)
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Rinne test
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detects difference b/t air conduction and bone conduction
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darwin's tubercle
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congenital, painless nodule of helix
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sensation of vertigo originates in
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semicircular canals
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aphthous ulcers
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canker sores of unknown cause
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cheilitis
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fissures at corners of the mouth
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epulis
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nontender, fibrous nodule of the gum
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koplik's spots
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blue-white spots w/red halo of oral mucosa; early sign of measles
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thrush
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oral candidiasis of newborn
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most common site of nosebleeds
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kiesselbach's plexus
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frenulum
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fold of tissue connecting the tongue to floor of the mouth
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colostrum
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thin, yellow fluid precursor to milk
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intraductal papilloma
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serosanguineous nipple discharge
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montgomery's glands
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sebaceous glands in areola that secrete protective lipids during lactation
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peau d'orange
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orange-peel appearance of breast due to edema
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tail of spence
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extension of breast tissue into the axilla; most common site of breast tumors
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lactiferous sinuses
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reservoirs for storing breast milk
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best timing for self-breast exam
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4-7 day of menstrual cycle
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angle of louis
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manubriosternal angle
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crakles
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rales; heard on inspiration
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crepitus
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coarse crackling palpable over the skin
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egophony
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sound of "eeee" heard through stethoscope
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kussmaul's respirations
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type of hyperventilation; dka
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rhonchi
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low-pitched snoring sound caused by obstruction d/t secretions
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wheeze
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high-pitched, squeaking lung sound
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pectus excavatum
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sunken sternum
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pectus carinatum
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forward protrusion of sternum
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cor pulmonale
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R ventricular hypertrophy and HF d/t pulmonary HTN
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paradoxical splitting
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S2 split, heard during expiration, fused in inspiration
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physiologic splitting
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S2splitting heard during inspiration
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allen test
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tests patency of radial and ulnar arteries by occluding both, releasing one to observe return of skin color
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homan's sign
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calf pain when foot is sharply dorsiflexed; DVT
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pulsus alternan
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regular rhythm, but force is alternating large and small amplitude
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pulsus bigeminus
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irregular rhythm, every other beat premature
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pulsus paradoxus
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weaker amplitude w/respiratory inspiration
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brawny edema
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nonpitting
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linea alba
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line down center of abdominal muscles
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location of spleen
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9-11th rib, L lateral side
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epigastric
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relating to anterior wall of abdomen; on or over the stomach
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organs found in RUQ (3)
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liver, gallbladder, duodenum
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organs found in LUQ (3)
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stomach, spleen, body of pancreas
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organs found in RLQ (2)
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cecum, appendix
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organ found in LLQ
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sigmoid colon
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location of abdominal aorta
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L of midline
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R kidney
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1-2 cm lower than L b/c liver placement
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GI considerations for pregnant women
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risk of reflux (pyrosis), constipation (b/c less peristalsis), hemorrhoids
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cullen's sign
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bluish halo around umbilicus d/t abdominal bleeding, pancreatitis
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grey turner's sign
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grayish colored flanks d/t severe peritoneal bleeding
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order of abdominal assessment
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Inspect, Auscultate, Percuss, Palpate
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blumberg sign
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rebound tenderness; press down on site away from pain, quickly release, pt feels pain there
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murphy's sign
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pain w/liver palpation; cholysistitis
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tests for appendicitis (2)
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iliopsoas muscle test, obturator test
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GI assessment considerations for infant & child
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do not percuss spleen
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leopold's maneuvers
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palpating baby in womb, moving to optimal positioning for labor
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caput medusa
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spider veins in stomach; common w/cirrhosis
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factors on color of areola
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parity (# of pregnancies, length of pregnancies), skin tone
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cooper's ligaments
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suspensory ligaments of the breast; become contracted w/breast cancer, causing dimpling
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risk factors for breast cancer
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age, early menstrual start age, history of 1st relative w/ b.c., older 1st pregancy
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gynecomastia
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male breast
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mastitis
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inflammatory mass of breast tissue
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breast abscess
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pocket of accumulated pus in breast tissue; breastfeeding must halt, but on antibiotics
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paget's disease
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friable breasts; carcinoma, yellow discharge
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cremaster muscle
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muscle of scrotum that shorten in cold weather to protect the temperature of the testis
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temp of testes
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3 degrees lower than abdomen
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condylomata
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warts
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phimosis
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foreskin is not retracted
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paraphimosis
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tightly retracted foreskin, fixed exposing glans penis continuously
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hypospadias
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urethra exits ventrally through penis
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epispadias
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urethra exits penis dorsally
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peyronie's disease
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painful bending of penis during erection, usually >45 y/o
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priapism
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prolonged painful erection w/o sexual stimulation
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Os
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circular hole in cervix
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goodell's sign
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softening of cervix in pregnant female
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chadwick's sign
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blue/purple/deep red cervix
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hegar's sign
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softening of isthmus b/c cervix and uterus
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mucus plug
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thick plug protecting fetus from infection; unblocks during labor
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batholin's gland
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gonorrhea
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cystocele
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pressure on vagina d/t bladder distention
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trichomoniasis
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frothy green discharge
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bacterial vaginosis
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fishy, profuse discharge
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ambiguous genitalia
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hyperplasia of adrenal glands
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rate of skin turnover
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4 weeks
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normal nail bed angle
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160 degrees
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danger signs for skin lesions r/t skin cancer
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ABCDE- assymetry, border, color, diameter, elevated
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target lesion
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lyme disease
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zosteriform lesions
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on a nerve track; shingles
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macule
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flat spot
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papule
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raise lesion <6mm
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mongolian spot
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normal dark bruise in darker skin tone
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koilonychia
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spoon nails
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phalen's test
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put dorsal surface of hands together- test for carpel tunnel syndrome
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bulge sign
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baollottement for effusion of knee
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mcmurray's test
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for meniscal tear
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ortolani's maneuver
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tests for congenital hip displasia in infants
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effects of mild sprain
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no tear in ligament, but increases chance of repeat injury
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treatment of sprain
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RICE- rest, ice, compression, elevation
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greenstick Fx
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not completely through the bone
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spiral Fx
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break at a sharp angle in bone
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comminuted Fx
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burst, shattered
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transverse Fx
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completely through bone, straight across
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compound Fx
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needs relignment, breaks skin
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RA
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congenital, always bilateral
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osteoarthritis
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from wear and tear on joints, can be unilateral
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fibromyalgia
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AI muscular disease
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bouchard's nodes
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in RA and OA; more proximal
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heberden's nodes
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in RA and OA; more distal
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Apex of heart
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PMI; point of maximum impulse
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baby's apex of heart
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4th intercostal space
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age at which apex is found @ 5th intercostal
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7 y/o
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S3
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denotes CHF, normal if <35 yo w/increased exercise; rapid ventricular filling
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S4
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denotes CAD, myopathy, HTN, stenosis
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normal time frame for murmurs
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first 2-3 days of life
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age at which lymphatic tissue reaches adult size
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6 y/o
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norm capillary refill
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1-2 sec.
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water-hammer/ corrigan's pulse
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4+, greater force followed by a collapse
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pulsus bigeminus
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coupled rhythm
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pulsus bisferiens
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2 peaks with a dip in between
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order cranial nerves
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OOOTTAFAGVAH; olfactory, optic, occulomotor, trochlear, trigeminal, abducens, facial, acoustic, glossopharyngeal, vagus, accessory, hypoglossal
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CN 7 tests
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puff cheeks, smile, frown
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CN 5 test
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TMJ, open, close mouth
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CN 3, 4, 6 test
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accommodation, follow through 6 planes
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strabysmus
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lazy eye
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pinguecula
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yellow nodule on sclera
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aphthous ulcers
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canker sores
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ankyloglossia
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short frenulum
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most rapid period of growth
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birth-4 mos.
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marasmus
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protein-calorie malnutrition
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pellegra
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niacin deficiency
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scorbutic gums
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vitamin c deficiency
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follicular hyperkeratosis
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vitamin a/linoleic acid deficiency
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bitot's spots
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vitamin a deficiency
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rickets
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vitamin D/calcium deficiency
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best marker of protein status/nutrition
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prealbumin
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how many pair of ribs
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12
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number of true ribs
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7 pair; 14
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suprasternal notch
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"u" between clavicles
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acinus
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respiratory unit; bronchiole, alveolar duct, sac, alveoli
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most influence in spurring respiration
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CO2 levels
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surfactant production begins
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32 wks
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type of breathing during pregnancy
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diaphragmatic
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pack yrs equation
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yrs smoking x packs a day
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bronchial/tracheal breath sounds
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short inspiration, long expiration
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bronchovesicular breath sounds
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inspiration = expiration
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vesicular breath sounds
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longer inspirations, shorter expiration
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lobar pneumonia
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consolidated alveoli
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atelectasis
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bronchial obstruction
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bronchitis
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inflammed bronchioles
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emphysema
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overdistended alveoli
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