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body systems

physicians assesement of the body system

TermDefinition
Appearance Body build, posture, gait. height/ weight fluctuation. Nutritional status. Hygiene/ grooming. Emotional state/ mood.
Head/ neck Size, shape, contour of head. Hair, scalp. Palpation of neck/ thyroid/trachea. difficultly swallowing, change in voice.
Eyes visual acuity/ field. Inspection of eyelids/ eyeballs. Papillary reaction and eye movement. Inspection of internal eye structures. Measure of ocular pressure.
Nose size/ shape/ symmetry. Deviated spectrum/ nasal congestion. sense of smell
Ears hearing deficit. Inspection of size, symmetry, placement. discharge, ringing in ears, infection.
Mouth/ throat Inspection of gums teeth tongue pharynx. Bad breath, changes in salivation. Sense of taste.
Respiratory size/shape of chest. Breath sounds. Phlegm, cough, sneezing, wheezing. Coughing of blood, asthma, emphysema. Upper/lower respiratory tract infections.
cardiovascular shortness of breath, chest pain. reflected pain in jaw, arms, upper back. Heart murmur, palpitations, night sweats. cold/bluish hands, leg cramps, varicose veins. Hypertension, valvular disease
Gastrointestinal Symmetry, tenderness, pain. Changes in appetite, nausea, vomiting. Jaundice, ulcers, gallstones. bowel sounds. Diarrhea, constipation, hemorrhoids, stool color.
Urinary changes in urination: hesitancy, urgency, frequency, night voiding, paid when voiding loss of steam force. Kidney stones, urinary tract infections. Dribbling, incontinence, indicators of infection.q
Genitalia (male) Infertility, sterility, impotence. Testicular pain/mass. Penile discharge/discomfort. Erections, hernias. Prostate/testicular enlargement.
Genitalia (female) menses regularity, flow, pain, duration. Premenstrual symptoms, menopause. Obstetric history, birth control method. Breast symmetry, discharge, masses. Estrogen therapy, reproductive surgeries. Pain during intercourse, sterility.
Lymph glands enlargement, tenderness
Neurologic level of consciousness, headaches. Reflex reactions, general weakness. Speech changes. memory loss, Seizures. Change in balance, lack of coordination.
Endocrine weight change, fatigue, bulging eyes. Increased thirst/ hunger, neck swelling. Excessive sweating, heat or cold intolerance.
Skin Color, turgor, tone. Lesions/ scars. Temperature, rashes, itching. moles, sores, acne.
Arms/ Legs General appearance/ symmetry. Palpation of arm muscles. Range of motion, limitation of movement. Inspection of fingernails. Deformities, joint stiffness. Gait.
Legs/ feet Symmetry, scars, bruises, swelling, open areas. Broken bones, deformity, sprains, strains. Gout, arthritis, osteoporosis. Inspection of toenails.
Created by: sno413
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