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14 Cards in this Set
- Front
- Back
General appearance
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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 |
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Head and Face
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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 |
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Ears
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Inspect for placement, shape, discharge
Palpate pinna, tragus, mastoid process ___________________________________ Finger rub Otoscopic exam: external canal, tympanic membrane, landmarks |
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Eyes
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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 |
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Nose
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Alignment
discharge mucosa Nares patent (sniff one side, then the other) ___________________________________ CN I: Identifies odor |
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Mouth and throat
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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 |
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Neck
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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 |
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Anterior Lungs
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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 |
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Heart
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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 |
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Lateral and Posterior Chest
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Inspect shape, configuration, and skin condition
Symmetry Tenderness ___________________________________ Expansion Tactile fremitus CVA tenderness Quality of lung sounds Adventitious sounds Egophony |
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Abdomen
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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 |
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Upper extremities
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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 |
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Lower extremities
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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 |
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Breast self-exam
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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 |
