The General Inspection

General condition: good, satisfactory, moderately grave, grave, extremely grave.

Consciousness: clear, alert; clouded; stuporous; soporouse; comatose; confused, irritative disorders (delirium, hallucinations).

Position: active, passive, forced.

Posture: right, erect, incorrect, stooped.

Gait: easy, steady, confident, paralitic, paretic, ataxic, hemoplegic, retarded, wobbly, spastic, waddling.

Physique (body build): asthenic, hypersthenic, normosthenic (athletic) type, regular, irregular.

Nutritional state: well nourished; poorly nourished; cachectic; obese; emaciated.

Head: correct, incorrect shape, square, flattened on top, normal size, microcephaly, macrocephaly, tremor, Musset’s sign, scars _________________________________

Face: puffy, Corvisart’s facies, facies febrile, acromegalic, myxoedematous, facies basedovica, moon-like, facies leonine, Parkinson’s mask, sardonic grin, Hippocratic face, symmetrical, asymmetric, serene, lifeless, dolorosa, adenoid, Stokes’ collar, asymmetric movements of facial muscles, unilateral ruddiness.

Neck: not changed, dilatation of veins (swelling and pulsation of the external jugular veins), pulsations of veins, arteries, “carotid shudder”, scars.

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Eyes: not changed; sunken, dilated eye slit, narrowing of the eye slit

Lids oedema ptosis width of palpebral fissures not changed

Sclera jaundice hemorrhage injection "rabbit eyes" not changed

Conjunctivae pallor injection petechiae not changed

Cornea scars ulceration arcus senilis not changed

Pupils not changed round equal miosis mydriasis anisocoria reaction to light and accommodation equal non-equal "pulsation" exophthalmos enophthalmos xanthomas

Ears: hearing not changed, decreased, tophi.

Skin

Colour flesh-coloured red pallid cyanotic icteric brown greenish tint cafe au lait

colour of palms

pigmentation not changed foci of depigmentation of the skin (vitiligo)

texture wrinkled

turgor and elasticity not changed decreased

moisture normal moist dry

moisture of palms

peeling

eruption

lesions

cutaneous striae

spider angiomata

scratch marks

scars

xanthomas

Nails: not changed, cyanosis, flattened, thickened, fragile, stratified, Hippocrate’s (like watch glass), spoon-like, brittle.

Hair: not changed, falling out, alopecia, hirsutism, hypertrichosis, fragility, grey.

Subcutaneous fat

Development moderate poor excessive

Distribution uniform nonuniform deposited in only certain parts of body

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Oedema evident generalized (anasarca) localized

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Lymph nodes impalpable palpable

Site occipital tonsillar anterior and posterior cervical preauricular postauricular supraclavicular axillary epitrochlear popliteal inguinal

Consistency soft elastic densely-elastic dense hard

Tender painless

Fixed mobile

size _____ × _____ mm

Breasts symmetrical ____________________________________________

nipple, ulceration, secretion, pigmentation, areola, tenderness, masses.

Blood vessels not changed varicose veins

Muscles __________________________________________________________

Development well poor developed muscular system hypotrophy atrophy

strength (force) normal weak powerful

tone normal hypertonia hypotonia rigidity

cramps tonic clonic

Joints _______________________________________________________________

Shape

Articulation active and passive mobility full reduced volume

tenderness present absent

swelling or deformity present absent

hyperthermia and oedema of the adjacent tissues present absent

Heberden’s nodes present absent

Bones ______________________________________________________________

Abnormality present absent

Deformation clubbing of fingers scoliosis present absent

Mobility

Curvature

vertebral tenderness to percussion

Дата добавления: 2015-11-14