General assessment

General inspection (observation) (inspectio).

General condition: good, satisfactory, moderate middle grave, grave, extremely grave.

Consciousness: clear, deranged (stupor, sopor, coma, twilight state, delirium).

Habitus (includes constitution i.e. body-build, high and body weight): normosthenic, hypersthenic, asthenic; stature – cm (normal, dwarfism (nanism, cretinism), gigantism), body weight – kg (normal, gain in weight, loss of weight).

Posture of the patient: active, active with restriction, forced (standing upright position, sitting position, (intolerance of the recumbent position) – orthopnoea, supine posture, the position lying on the side (on the affected or healthy side), opistotonus, the prone position (lying face down), on several pillows, the forced “knee-elbow position”, the state of restless etc.), passive.

Gait:

The skin: color (usual, pale, red, bronze, cyanotic, yellow or icteric: a degree of expressiveness – subicterus or jaundice, tint of icteric — lemon-yellow (haemolytic), orange-yellow, greenish-yellow, grayish-brown or brown); local hyperpigmentation, grayish (dirty), depigmentation. Turgor and elasticity, sweating (normal, hyperhydrosis), dryness, peeling, eruption (erythema, roseola, papula, vesicla, pustule, weals or urticaria, hemorrhage lesions (petechia, ecchymoses, purpura, hematoma), telangiectasia,) — site (localization), solitary, plural, confluent; vascular "asterisks" (size, localization); scars: posttraumatic, postoperative (size, localization); trophic changes: ulcer, pressure sore (localization, size, character of a surface). Hair: baldness (premature, partial, general), canities, hypertrichosis. Nails: fragility, deformations (watch-glass nails, hypertrophic (sclerohychia), spoon-shaped (koilonychia), onychia diabetica, half and half nails etc.).

Tunica mucosa of lips, nose, eyelids: color — pink, red, pale, cyanotic discoloration; pigmentation.

Subcutaneous fat: degree of expressiveness (normal fat, skinfold thickness in hypochondrium: deficiency, excessive), accumulation of fat mainly (upper part of body, abdomen, buttock, legs), obesity (or peripheral or buttock-thigh and android or central or abdominal), insufficient accumulation, emaciation (demetritio, dystrophia, cachecxia).

Oedema: localization (podedema, cruses, loin, face, general) (general, local), expressiveness (slight, small, moderate, significant, anasarca), consistency (friable, easily move on a gravity at change of position, dense), genesis (cardiac failure, hypoproteinaemia, renal, congestive, cachectic, hypothireoidum etc.).

The lymph nodes: localization palpable units (submandibular, parotid, cervical, occipital, supraclavicular, infraclavicular, axillary, cubital, inguinal, under knee), size (to specify in cm), shape (roundish, awkward), consistency (soft, elasticity, firm), surface (smooth, rough), pain (painful, painless), mobility (adherence together and with surrounding tissues (matted, not matted)), color of the skin over lymph nodes.

The locomotor system:

Muscular system: the level of development (good, moderate, weak), hypotrophy and atrophy, tenderness (at what groups) or painlessness, tremor of extremity, muscular tonus, cramps, contractures.

Bones system: deformities (visible and palpable), tenderness at palpation or percussion; hippocratic fingers (clubbing of the terminal phalanges and toes).

Joints system (articulations): shape, configuration (usual, deformity, defiguration, swelling), symmetrical. Active, passive movements (it is enough, it is limited, contracture, anchylosis — which joints), tenderness at palpation or movements (active, passive), a crunch in joints, fluctuation, hyperemia, nodules in periarticular tissue (so-called Heberden’s nodes); vertebral column: without features, pathological curvatures (lordosis, kyphosis, scoliosis, kyphoscoliosis), restriction of mobility, tenderness at movements.

Countenance: usual, excited, indifferent, masklike, stupid (blunt), puffy, Cushing’s syndrome - "moon-like", Corvisart’s face, febrilis, cyanotic ruddiness, erythema as «butterfly», nose’s wings participation in breathing.

Eyes: Eyeball: exophthalmia, enophthalmia, anophtalmia, microphtalmia, squint (strabismus), nystagmus. Eyelids: ptosis, oedema, symptoms of Gref, Moebius, Shelvag. Eye slit: epicanthus, hyperthelorism. Sclera (color, icteritiousness or jellow, bleeding into the conjunctive); Kayser-Fleischer ring. Pupils: identical, anisocoria, miosis, mydriasis, reaction to light (alive, languid, absent), accommodation, convergence.

The Mouth. Mucous membrane: color (yellowish, pale etc), pigmentation, enanthema, haemorrhages, ulcers. Tongue: clean, coated or furred (white, white-grey, white-dirty, white-yellow, crimson-red etc.), dry or moist; papillary layer (usual, atrophy, hypertrophied), surface (smooth, grooved (fissured tongue), "polished", local thickening "geographical"). The Gums (gingiva): usual, swollen, hypertrophied, bleeding. Teeth: caries, missing teeth. The t onsils: not increased, increased, hyperemic, presence purulent proside in lacunas, hemorrhage. Smell (from a mouth): halitosis, putrefactive, «rotten eggs», fruit, uric.

The thyroid gland: size: is not increased, enlargement (goitre) (degree of increase), consistence (elastic, soft, dense, presence of separate units in it), surface (smooth, tuberous), pain, tenderness.

Дата добавления: 2015-11-16