Term
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Definition
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Term
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Definition
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Term
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Definition
optic
snellen chart
peripheral vision
opthalmoscope exam |
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Term
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Definition
oculomotor, trochlear, abducens
extraocular movement, PERRLA |
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Term
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Definition
trigeminal
touch with cotton ball
clench teeth |
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Term
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Definition
facial
smile, frown, puff out cheeks
close eyes and resist |
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Term
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Definition
acoustic
whisper
weber
rinne |
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Term
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Definition
glossopharyngeal
ah
soft palate
uvula |
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Term
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Definition
vagus
gag not tested
ability to swallow and speak |
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Term
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Definition
spinal accessory
shrug shoulders against hand
turn head against hand |
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Term
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Definition
hypoglossal
tongue up, down, side to side |
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Term
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Definition
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Term
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Definition
slightly tanned
nevi
lesions
even tone |
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Term
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Definition
few varicose veins
superficial vessels are visible |
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Term
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Definition
none present
if present i would note the size, color, type, group, and distribution |
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Term
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Definition
well trimmed
attached to nail plate
transparent with white tips
capillary refill under 2 seconds |
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Term
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Definition
no edema present
if so rate it
1+ for mild pitting, 2+ moderate pitting, 3+ deep, 4+ very deep pitting |
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Term
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Definition
warm to touch
even on both sides |
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Term
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Definition
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Term
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Definition
| turgor is quick to return |
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Term
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Definition
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Term
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Definition
chest is symmetrical. no barrel, pigeon or funnel chest
AP to transverse ratio is 1:2 which is normal |
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Term
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Definition
| 30 seconds, multiply by 2 and not rhythm |
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Term
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Definition
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Term
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Definition
| chest expands symmetrically and bilaterally |
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Term
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Definition
please lean forward slightly and cross arms over chest to expand the thoracic area
normal tone is resonant throughout |
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Term
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Definition
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Term
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Definition
im going to listen to your lungs, please breathe a little deeper than you normally would
lungs clear to auscultation bilaterally
no adventitious sounds
normal breath sounds are bronchovesicular over central airways
vesicular over peripheral lung tissue |
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Term
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Definition
normally i would palpate each for 30 seconds and multiply by 2
when palpating i would state that
0 is absent
1 is weak
2 is normal
3 is increased
4 is bounding
temporal is 2+
carotid 2+
brachial 2+
radial 2+
ulnar 2+
femoral is in the groin area
politeal 2+
dorsalis pedia 2+
posterior tibialis 2+ |
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Term
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Definition
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Term
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Definition
the head of the bed is usually elevated to 45 degrees but here the head is flat
please look to your left
im going to place my ruler at the angle of louis
look for pulsations
and measure the highest section of pulsations
jugular venous pressure is ___ which is normal |
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Term
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Definition
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Term
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Definition
im gong to look for pulsations retractions or heaves
now im going to palpat the base, left sternal border, and apex for pulsations or thrills.
none felt |
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Term
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Definition
normally i would listen to each area for 30 seconds and over the mitral for a full minute
i would also use the mitral for the apical pulse in which i would count the heart rate for a full minute
ill start at the right 2nd intercostal space, the aortic
left 2nd intercostal space the pulmonic
left 3rd intercostal space Erb's point
left 4th intercostal space tricuspid
left 5th intercostal space at the mitral area
no sounds of gallops or rubs noted
now im going to compare to carotid pulse to the S1 sound at the mitral area
heart rate has a regular irregular rhythm
S1 and S2 are present
S1 is synchronous with the carotid pulse
S1 is heard louder at the apex and S2 is louder at the base
S1 can also be heard in left lateral recumbent position and having the patient sitting up and leaning forward
now im going to switch to my bell and listen to the points backwards |
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Term
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Definition
| skin is even toned with nor scars |
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Term
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Definition
imbilicus is inverted
midline
no signs or protrusion or inflammation |
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Term
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Definition
| abdomen is symmetrical and slightly convex |
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Term
| please take a deep breath |
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Definition
| no pulsations or masses are present that protrude or can be seen |
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Term
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Definition
normally i would listen to the 4 quadrant for one minute
if no bowel sound were heard i would listen for 5 minutes
normal active bowel sounds found in all four quadrants |
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Term
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Definition
now im going to listen for bruit with the bell over the abdominal aorta
renal arteries
iliac arteries, and noramlly the femoreal arteries but they are in the groin area
i would lsiten for 30 secs in each position for the prsence of bruit
if bruit were noted it would not be safe to percuss or palpate |
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Term
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Definition
| tone is resonant throughout |
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Term
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Definition
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Term
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Definition
lightly, then deep
palpatin smooth thorughout
no masses or enlarged organs
no muscular rigidity or tenderness |
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Term
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Definition
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Term
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Definition
please close your eyes and hold your arms out to the side
please touch your nose with your hand
now open you eyes and touch your finger to my finger then to your nose |
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Term
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Definition
| please flip your hands back and forth like this quickly |
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Term
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Definition
| please put your heel on your shin and move it down |
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Term
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Definition
| now please make a figure 8 with that foot |
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Term
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Definition
could you please grab my fingers?
please resist my push
arms: in, out, up, down
thighs: in out up down
legs: up down
feet: plantar, dorsi
motor strength is 5 out of 5 |
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Term
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Definition
please close your eyes, im going to touch you with a cotton ball
please point to where i am touching you |
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Term
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Definition
please close yoru eyes im going to touch you witha cotton swab
please tell me if you feel it sharp or dull
this is sharp, this is dull |
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Term
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Definition
| tell me when yo ufeel the vibration on your fingers and when you feel it stop |
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Term
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Definition
| please tell me if your finger is up or down |
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Term
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Definition
please tell me if there are one or two points
this is one
this is two |
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Term
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Definition
im going to place an object in your hand
please identify what it is |
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Term
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Definition
| im going to write a number in your hand please tell me what it is |
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Term
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Definition
bicep
tricep
patella
achilles
babinski reflex (no response, negtive for babinski reflex) |
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Term
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Definition
| gait is steady and well coordinated |
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Term
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Definition
eyes closed, palms up, feet together
normally for 20 seconds
some swaying is normal
patient is negative for romberg |
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Term
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Definition
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