Term
| GENERAL INSPECTION / VITAL SIGNS |
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Definition
1. Rechecks blood pressure in one arm/appropriate cuff placement
2. Palpates both radial pulses
3. Times radial pulse
4. Checks range of motion in both arms
5. Inspects and palpates both hands, fingers and fingernails |
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Term
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Definition
. Inspects eyes (retracts lids, etc.)
7. Checks for convergence (finger in and out)
8. Observes pupillary response to light (direct and consensual)
9. Checks for near reflex ( “accommodation”)
10. Tests visual field by confrontation (look into their eyes) |
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Term
| EYES (OPHTHALMOSCOPIC EXAMINATION) |
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Definition
6. Inspects eyes (retracts lids, etc.)
7. Checks for convergence (finger in and out)
8. Observes pupillary response to light (direct and consensual)
9. Checks for near reflex ( “accommodation”)
10. Tests visual field by confrontation (look into their eyes) |
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Term
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Definition
17. Examines ears bilaterally with otoscope
18. Tests for auditory acuity (whisper, finger rub, or watch tick, etc.)
19. Pull on auricle and push on tragus |
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Definition
20. Tests for nasal patency both sides
21. Inspects nasal vaults with speculum on otoscope
22. Palpates/percusses for (frontal or maxillary) sinus tenderness |
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Term
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Definition
23. Inspects lips, gums, tongue, and teeth
24. Inspects floor of mouth and base of tongue
25. Inspects posterior pharynx
26. Observes elevation of the palate (roof of mouth) by having patient say "ah" |
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Term
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Definition
27. Evaluates extraocular muscle function in 6 directions
28. Palpates clenched masseter muscles (nerve V)
29. Tests upper (e.g. raises eyebrows) and lower (e.g. smile) nerve VII
30. Tests head rotation against resistance or shoulder shrug (nerve XI)
31. Observes midline protrusion of tongue (nerve XII)
32. Tests facial sensation bilaterally (nerve V)
33. Asks about gag (nerve IX,X) |
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Term
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Definition
Palpates lymph nodes in the following areas:
34. Around ears
35. Anterior cervical chain (in front of sternocleidomastoid muscle)
36. Posterior cervical chain (behind and posterior to sternocleidomastoid muscle)
37. Supraclavicular (above collarbone)
Other parts of the neck exam:
38. Palpates thyroid without swallowing (isthmus and lobes)
39. Palpates thyroid with swallowing (isthmus and lobes) |
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Term
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Definition
40. Performs fist percussion of or palpates vertebrae
41. Performs fist percussion of CVA (kidneys for punch tenderness) |
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Definition
THORAX
42. Checks for chest expansion (hand around back)
43. Percusses lung fields bilaterally and symmetrically
44. Auscultates lung fields bilaterally and symmetrically
45. Asks patient to breathe through open mouth
46. Asks about breast exam. (STUDENT NOT TO PERFORM ACTUAL EXAM.)
47. Feels for axillary nodes bilaterally |
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Term
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Definition
HEART
48. Positions patient with head elevated at 45°, looks for JVD
49. Observes precordium (looks at anterior chest)
50. Palpates chest wall or point of maximum impulse
51. Uses both diaphragm and bell (if stethoscope has bell) to auscultate
52. Auscultates all 4 areas (aortic, pulmonic, mitral, tricuspid)
53. Palpates carotids bilaterally
54. Auscultates carotids bilaterally |
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Term
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Definition
55. Auscultates before manipulation or palpation
56. Palpates all 4 quadrants
57. Feels midline for aorta
58. Auscultates midline for bruit
59. Percusses liver span |
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Term
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Definition
60. Palpates lower extremity pulses (dorsalis pedis and posterior tibial)
61. Checks for leg edema |
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Term
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Definition
Arms
62. Tests arm muscles (arms extended against resistance)
63. Tests forearm muscles (flex/extend elbows against resistance)
64. Tests hand muscles (grip strength, interosseous muscles, break ring of thumb and index finger)
Legs
65. Checks range of motion in both legs
66. Tests leg muscles (done if patient can hop or do deep knee bend)
67. Tests calf and foot muscles (ask patient to flex/extend ankle against resistance |
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Term
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Definition
Reflexes
68. Biceps
69. Triceps
70. Brachioradialis
71. Patellar reflex
72. Achilles reflex
Cerebellar
73. Tests rapid alternating movements-hands
74. Tests finger-to-nose bilaterally
75. Tests heel-to-shin (knee to ankle)
76. Performs Romberg test
77. Observes gait
78. Observes tandem gait (heel to toe)
Sensory
79. Tests light touch OR light pain (sharp vs. dull) in feet or hands
80. Tests position sense OR vibration sense in feet or hands |
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Term
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Definition
| 81. Asks about rectal / genital exam (STUDENT NOT TO PERFORM ACTUAL EXAM) |
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Definition
82. Asks if any final questions
83. Summarizes problems |
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