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19 Cards in this Set
- Front
- Back
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General
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sick v not sick
nutritional status mood, pain level sweating, cold, pallor, cyanosis, jaundice sexual development involuntary movements gait, posture level of consciousness: intoxicated, high, drowsy |
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head
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size, shape
facial symmetry sinus tenderness |
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eyes
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spacing, shape, edema, EOM, strabismus
PERRL (pupils equal round and reactive to light) red reflex fundi: optic disc (papilledema=swelling), hemorrhages discharge jaundice, redness nystagmus (prepetitive motion back and forth or up and down) visual activity and visual fields |
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ears
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size, shape, placement
canal, tympnic membrane acuity, lateralization |
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nose
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mucosa, turbinates, septum
polyps |
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mouth and pharynx
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color, hydration
discharge, lesions dentition masses |
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neck
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lymph nodes (cervical, auricular, occipital, submental, tonsilar, submandibular, supraclavicular)
masses thyroid (nodules, goiter) |
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chest
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axillary lymph nodes
shape (barrel-chested, shield) breath sounds (rales-crackles, rhonchi, wheezing) symmetry, reactions, rate heart sounds (murmur, click, rub, PMI, rate, rhythm, S1 and S2) breasts (sexual development (Tanner stage), lumps, skin, nipple discharge) |
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abdomen
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sounds or lack of
shape: ascites (fluid) liver size spleen size masses tenderness femoral lymph nodes, pulses |
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genital/urinary
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shape (newborn: ambiguous genitalia, hypospadius-urethral opening is too low)
external lesions, adhesions, rashes, warts, penile or vaginal discharge male: Tanner stage, testes descended, hernia, penis female: Tanner stage, vagina, cervix, ovaries, uterus |
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rectum
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tone
impaction hemorrhoids, masses prostate |
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back
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CVA tenderness (costovertebral angles=flank=kidney)
scoliosis |
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skin
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turgor (hydration status)
rash macule, patch-flat papule, nodule, wheal-raised vesicle-fluid pustule-pus erosion, ulcer, fissure crust, scale, atrophy, excoriation (scraped) color: red, hypo/hyperpigmented, mottled bruises: petechiae (low platelets) |
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neuro: mental status
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speech and language
cognitive function: oriented, memory, thought processes |
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neuro: cranial nerves
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smell
muscle strength: temporal, masseter, trapezius, sternomastoid facial movements or paralysis corneal reflexes gag reflex |
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neuro: motor system
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major muscle groups: strength, muscle, tone
cerebellar function |
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neuro: sensory system
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pain
temperature light touch vibration discrimination |
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neuro: deep tendon reflexes
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hit knee with reflex hammer
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Limbs, hands, feet
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Range of motion (ROM)
length, proportion, shape (bowlegged, knock-kneed) joints and skin: redness, edema, varicose veins muscle atrophy |
