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34 Cards in this Set

  • Front
  • Back
General Appearance
1. level of conciousness
2. signs of distress
3. apparent state of health
4. skin color and obvious lesions
5. appropriate sexual development
6. posture, gait, motor
7. dress, grooming, hygiene
8. odors of body or breath
9. facial expression
Nails
color
shape
texture
lesions
capillary refill
Skin General Characteristics
1. color
2. moisture
3. temperature
4. texture
5. mobility and turgor
6. lesions (location, distribution, arrangement, type, color)
Head
quantity
distribution
texture
pattern of loss
nits or dandruff
scalp inspected and palpated
facies
Eyebrows
quantity
distribution
scaliness
Eyelids
position in relation to eyeballs
width of palpebral fissure
edema
color
lesions
condition and direction of eyelashes
adequacy of eyelid closure
lacrimal gland
lacrimal sac for swelling
Conjunctiva and Sclera
color
vascular pattern
nodules
swelling
Cornea, Lens, Iris
cornea and lens for opacities
iris for clear markings
Pupils
size
shape
symmetry
EOM's
conjugate movements
nystagmus
lid lag
(and test for convergence)
Optic disc
clarity of disc outline
yellowish orange to creamy pink color
size of central cup
Retina
arteries
veins
inspects fovea/macula
Auricles
deformities
lumps
lesions
Ear Canal
discharge
FB's
redness
Eardrum
color
contour
cone of light
handle of malleus
short process of the malleus
pars flaccida
pars tensa
Nasal Vestibule
asymmetry
deformity
Turbinates
color
swelling
bleeding
exudates
Nasal septum
deviation
inflammation
perforation
abnormalities
Lips
color
moisture
lumps
ulcers
cracking
scaliness
Oral mucosa
color
ulcers
white patches
nodules
Neck
symmetry
scars
masses
enlargement of parotid glands
enlargement of submandibular glands
visible lymph nodes
Describing nodes
size
shape
delimitation
mobility
consistency
Murmur attributes
timing
shape
location of max intensity
radiation
intensity
quality
PMI
location
diameter
amplitude
duration
peripheral vascular- upper extremities
size
symmetry
venous pattern
texture
color
peripheral vascular- lower extremities
size
symmetry
color
texture
venous pattern
hair distribution
pigmentation, rashes, scars, or ulcers
(and palpate inguinal nodes)
Chest
rate and rhythm of resp.
deformities
use of accessory muscles
retractions of interspaces
respiratory lag
abdomen
scars
striae
contour and symmetry
pulsations
peristalsis
dilated veins
rashes
masses
signs of inflam
hernias
joints/cervical spine
tenderness
heat
enlargement
crepitations
nodules
joints NOT any spine
symmetry
swelling redness
MCP
swelling
bogginess
tenderness
Neuro exam
1. what is the date
2. where are you
3. name 3 object
4. spell WORLD backwards
5. recalls objects above
6. what is this?
7. no ifs ands or buts
8. fold paper
9. paper says Close your eyes
10. write a sentence
11. copy intersecting pentagons
cranial nerves
1(olfactory)- patency, sense of smell
2(optic)- acuity, fields, fundo
2 and 3(oculomotor)- size and shape of pupils, reaction to light and accomodation
3,4,6- EOM's, convergence, ptosis, nystagmus
5- temporal and masseter, pain sensation, light touch on 3 areas of face, corneal reflex
7 (facial)- raise eyebrows, frown, close eyes, show upper and lower teeth, smile, puff out cheeks
8 (acoustic)- auditory acuity, weber, rinne
9, 10 (glosso, vagus)- say "ah", gag reflex
11 (accessory)- look for atrophy and fasciculation, shrug shoulders, rotate head
12 (hypoglossal)- tongue for atrophy or fasciculation, protrude tongue for deviation from midline
muscle strength
body position, involuntary movements, muscle bulk, then test for muscle tone