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Physical Assessment

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Erythema Redness of the skin.
Cyanosis Bluish coloring of the skin and mucous membranes.
Jaundice Yellow appearance of skin.
Pallor Paleness of the skin.
Ecchymosis Collection of blood in subcutaneous tissues that causes a purplish discoloration.
Petechiae Small, purplish hemmorragic spots on the skin that do not blanch with applies pressure
Lesion Any abnormal tissue on the skin.
Wound Injury that results in a disruption in the normal continuity of the body tissue.
Rash A change of the skin which affects its color, appearance or texture.
Diaphoresis Excessive sweating commonly associated with shock or other medical conditions.
Turgor Tension of the skin determined by its hydration.
Edema Accumulation of fluid in extracellular spaces.
Pitting Edema Edema in which fluid builds up in the extremeties to such a degree that when the fluid filled extremity is gently pushed with a finger, a depression will remain in the flesh for some time before the flesh slowly bounces back into place.
Beau's Lines Deep grooved lines that run from side to side on the fingernail.
Paronychia A nail disease in which often tender bacterial or fungi hand infection where the nail and skin meet at the side or base of the nail.
Clubbing Rounding and swelling of nail beds.
Alopecia Baldness.
Hirsutism Excessive hairiness.
Periorbital edema "puffy" or swelling around the eyes.
Mydriasis Dilation of pupil due to disease, use of drugs or trauma.
Miosis Constriction of pupil of the eye resulting from normal response to an increase in light or caused by certain drugs or pathological conditions.
Accommodation Ability to adjust the eye to see at various distances.
Convergence Following an object as it nears your face. Becoming cross-eyed in the process.
Ptosis Drooping of upper or lower eyelid.
Entropion Medical condition in which the eyelid (usually lower one) folds inward.
Ectropion Condition where lower eyelid folds outwards.
Nares Nostril or nasal passages./
Lymphadenopathy Term meaning disease of the lymph nodes.
Barrel Chest A increase in the anterior posterior diameter of the chest wall resembling the shape of a barrel, most often associated with emphysema.
Fremitus Vibration of the chest wall that can be palpated during physical assessment.
Resonance Heard during percussing a patient.
Tympany Heard when percussing a patient. Hollow sounding.
Stertorous Breathing Loud breathing.
Stridor Harsh, high-pitched sound usually heard in inspiration when upper airways become narrowed.
Bruit Unusual sound, usually abnormal, heard in auscultation.
Phlebitis Inflammation of a vein.
Striae Irregular areas of skin that look like bands, stripes or lines.
Atrophy Decrease in size of body structure.
Crepitus (crepitation) Grating, crackling or popping sounds and sensations experienced under the skin and joints.
Aphasia Acquired language disorder in which there is an impairment of language use.
Hygiene/ Grooming clean, disheveled, clothes dirty, clothes inappropriate for the season, dressed for occasion, hygiene/grooming performed by staff, unkempt
Body Build small, medium, or large frame, flabby, firm, malnourished, obese
Affect

appropriate, flat, inappropriate, labile, blunted, paranoid, euphoric

Mood happy, sad, anxious, frustrated, tense, cooperative, restless, contented, angry, indifferent, detached
Skin Color tanned, vitiligo, freckled, erythema, ecchymosis, increased pigmentation
Lesions/ Abnormalities

striae, moles, birthmarks, petechiae, blister, nodule, pustule, cyst, ulcer, scale, keloid, cherry angioma, spider angioma, hematoma, senile keratosis, fissure, abrasion, scratch, skin tear, scar, lentigo senilis (age spots), senile purpura (vivid purple patches), skin tags

Nail Texture Smooth, ridged
Nail Color pink, cyanotic, yellowed
Hair Distribution

full, thin, even, patchy, receding hairline, male pattern baldness

Head Size small, average, large
Head Shape round, oval, square, pointed, asymmetrical
Eye Placement normal, high, low, aysmmetrical
Sclera Color white, red, yellow, dirty white related to aging
Vision

VISION: normal with glasses, holds items close to face to see, unable to reach newspaper, unable to see objects at a distance, describe what you observe about the patient’s ability to see both far and near objects

S1 and S2

clear, crisp, muffled, soft, unable to distinguish the two sounds, swish, click, loud

Vein Patterns visible, non-visible, varicosities (identify where), prominent
Chest Movement symmetrical, asymmetrical
ROM

full, MAE equally, jerky movements, uncoordinated, slow, limited with pain, weak, strong

Gait

Shuffling, propulsive, limping, pigeon toed, slapping, toes point outward (duck walk), smooth, coordinated, drags one leg, unable to walk, scissor, ataxia

Balance Steady, erect, leans to side (identify the side), sits erect in wheelchair, leans forward, leans backward