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physicians assesement of the body system

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Term
Definition
Appearance   Body build, posture, gait. height/ weight fluctuation. Nutritional status. Hygiene/ grooming. Emotional state/ mood.  
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Head/ neck   Size, shape, contour of head. Hair, scalp. Palpation of neck/ thyroid/trachea. difficultly swallowing, change in voice.  
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Eyes   visual acuity/ field. Inspection of eyelids/ eyeballs. Papillary reaction and eye movement. Inspection of internal eye structures. Measure of ocular pressure.  
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Nose   size/ shape/ symmetry. Deviated spectrum/ nasal congestion. sense of smell  
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Ears   hearing deficit. Inspection of size, symmetry, placement. discharge, ringing in ears, infection.  
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Mouth/ throat   Inspection of gums teeth tongue pharynx. Bad breath, changes in salivation. Sense of taste.  
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Respiratory   size/shape of chest. Breath sounds. Phlegm, cough, sneezing, wheezing. Coughing of blood, asthma, emphysema. Upper/lower respiratory tract infections.  
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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  
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Gastrointestinal   Symmetry, tenderness, pain. Changes in appetite, nausea, vomiting. Jaundice, ulcers, gallstones. bowel sounds. Diarrhea, constipation, hemorrhoids, stool color.  
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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  
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Genitalia (male)   Infertility, sterility, impotence. Testicular pain/mass. Penile discharge/discomfort. Erections, hernias. Prostate/testicular enlargement.  
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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.  
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Lymph glands   enlargement, tenderness  
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Neurologic   level of consciousness, headaches. Reflex reactions, general weakness. Speech changes. memory loss, Seizures. Change in balance, lack of coordination.  
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Endocrine   weight change, fatigue, bulging eyes. Increased thirst/ hunger, neck swelling. Excessive sweating, heat or cold intolerance.  
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Skin   Color, turgor, tone. Lesions/ scars. Temperature, rashes, itching. moles, sores, acne.  
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Arms/ Legs   General appearance/ symmetry. Palpation of arm muscles. Range of motion, limitation of movement. Inspection of fingernails. Deformities, joint stiffness. Gait.  
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Legs/ feet   Symmetry, scars, bruises, swelling, open areas. Broken bones, deformity, sprains, strains. Gout, arthritis, osteoporosis. Inspection of toenails.  
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Created by: sno413
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