Title
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Physical Assessment
correlated with health history |
Health of present illness |
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past health history |
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family health history |
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sequential |
IPPA, cephalocaudal |
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also include pertinent negatives, not only the symptoms |
General Survey
Body build |
Sthenic |
overall body build proportion |
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Morph |
classification of body types |
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Somatotypes |
Ectomorph |
thin, long limbs, minimal fat |
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Endomorph |
round belly, more fat, soft build |
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Mesomorph |
muscular |
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Abnormalities |
Marfan's syndrome |
long limbs |
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Acondroplastic dwarfism |
short limbs, large head, small face |
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Turner's syndrome |
short femorals, webbed neck, broad chest |
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Gigantism |
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Osteoporosis |
weak bones, stooped posture, height loss |
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Cushing's syndrome |
trunk fat, moon face, excess cortisol |
Posture/Gait
Posture |
Forward Bend Test |
Gait |
Let patient walk towards you for 3m (10-20ft) |
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Abnormalities |
Kyphosis |
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Lordosis |
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Scoliosis |
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COPD clients |
leans and brace |
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tripod position |
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slumped |
depression |
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anxious |
tense, stiff |
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steppage gait |
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spastic gait |
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propulsive gait |
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scissor gait |
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shuffling gait |
Skin
Abnormalities |
carotenemia, albinism |
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Edema Assessment |
Pitting |
pit stays |
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Non-pitting |
rebound skin |
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1. Sit patient with leg dangling |
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2. press tibia 30s to 1min |
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Inspect, palpate, & describe skin lesions |
Primary lesions |
macule, patch, papule, nodule, plaque, vesicle, bulla, postule, cyst |
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Secondary lesions |
scale, crust, scar, excoriation, fissure, erosion, ulcer, scar |
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Skin Turgor |
assess for dehydration |
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Location |
child/adult |
forehead, cheast, abdomen, arms, legs |
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elderly |
chest, abdomen |
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Findings |
>30s |
dehydrated |
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hard to pinch |
edema |
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sagging |
elderly |
Nail
Clubbing |
Schamroth Test |
Paronychia |
infection around the nail |
Koilonychia |
convex shape, iron deficiency |
Head & Face
Symmetry Test |
elevate brow |
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lower brow |
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close eyes |
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puff cheeks |
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smile |
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show teeth |
Eyes
Eyebrows |
raise & lower eyebrows |
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ABN |
scaling, thinning, uneven movement |
Eyelashes |
distribution, curled, clean |
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ABN |
loss |
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inflammation |
blepharitis |
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inward curl |
entropion |
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outward curl |
ectropion |
Eyelids |
lift eyebrow with thumb and index position |
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average blink speed 15-20 |
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ABN |
drooping lid |
ptosis |
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entropion |
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ectropion |
Conjunctiva |
palpebral, bulbar |
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ABN |
conjunctivitis |
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bloodshot eyes |
Lacrimal Ducts and Glands |
palpate |
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ABN |
dachyocystitis |
inflammation due to obstruction |
Cornea |
test corneal reflex |
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ABN |
opaque, rough surface |
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arcus sehilis |
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arcus juvenilis |
PERRLA |
ABN |
Aniscoria |
unequal pupil; stroke patients |
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Miosis |
extreme constriction |
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Mydbriasis |
extreme dilation |
Visual Aquity |
Snellen's Chart |
distance vision |
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Rosenbaum Eye Chart |
near vision |
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Penlight |
light perception test |
Functional Vision Test |
Count Fingers |
distance at 1ft |
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Hand Movement |
move 30cm |
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Light Perception |
penlight at side |
Visual Fields |
ABN |
Homoporous Hemianopia |
same side loss of vision on both eyes |
Terms |
OD |
right eye |
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OS |
left eye |
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EOM |
extraocular movement |
Ear
Whisper Test |
Rinne Test |
air conduction>bone |
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+ result normal |
Weber test |
equal |
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+ result normal |
Ear
Whisper Test |
Rinne Test |
air conduction>bone |
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+ result normal |
Weber test |
equal |
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+ result normal |
Nose
Sinuses |
Maxilla |
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ethmoid |
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frontal |
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sphenoid |
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