Term
A. General assessment strategies |
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Definition
1. Gather supplies before beginning |
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2. Adequately explain what is being done, while limiting small talk |
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Definition
3. Consider client's anxiety and fears. |
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4. consider own facial expression and comments |
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Definition
5. Demonstrate confidence, empathy, and gentle manner |
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Demonstrate confidence, empathy and gentle manner |
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Definition
6. Acknowledge and apologize for any discomfort caused |
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Term
7. Provide for privacy and warmth at all times |
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Definition
8. Determine comfort level, pausing if patient becomes tired |
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Term
9. Coordinate procedures to limit position changes for examiner and client |
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Definition
*10. Wash hands at appropriate times |
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Term
11. Briefly summarize findings to client, and thank client for his/her time. |
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Definition
12. Use appropriate terminology and correctly pronounces medical terminology with client |
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Term
13. Demonstrate skills of inspection, percussion, palpation and auscultation in the correct order for each system with the correct technique |
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Definition
14. Demonstrate correct use of instruments, including assembly and manipulation of component parts. |
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Term
15, Complete assessment in scheduled time |
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Definition
16. Refer to notes minimally. |
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Term
B. General survey of Client |
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Definition
1. gather name, age, sex and occupation |
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Term
2. Level of consciousness (arousal, wakefulness) |
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Definition
3. Obvious physical deformities |
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Term
4. Facial expression: Note distress |
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Definition
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Definition
short and long term memory assessed |
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Term
c. Standing in front of the client, client is sitting. |
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Definition
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Definition
*inspect fingernails, note nail bed color |
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Definition
d. palpate nails for capillary filling: fingernails |
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Term
e. inspect skin color and pigmentation. notes cyanosis |
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Definition
f. palpates skin temperature |
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Definition
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*note color of lesion. (must have some type of lesion for students to eval) |
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Definition
*note pattern or shaw of lesion. |
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Term
*note any lesions: use ABCDE |
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Definition
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*Note length, width, and elevation of lesion in centemeters |
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Definition
*Note location and distribution of lesion |
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Definition
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Definition
*Palpate radial pulses bilaterally. Scale 0-+4 noted |
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Term
*Palpate brachial pulsees bilaterally |
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Definition
Palpate arms to shoulders |
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Term
J. Assess range of motion (ROM) |
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Definition
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Definition
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Definition
L. Assess muscle strength of upper extremities |
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*n. rapid alternating movements |
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Definition
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Definition
q. assess epitrochlear nodes |
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Term
*r. assess axillary nodes |
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Definition
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a. Inspect and palpate scalp, hair and cranium |
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Definition
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Definition
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C. Palpate and percuss maxillary sinuses, frontal sinuses |
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Definition
d. auscultate temporal artery for bruits |
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Term
*e FaceL lightly touch either one or both sides of each of the three divisions of the trigeminal (CN V) |
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Definition
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Term
a. Hirschberg (corneal light reflex) |
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Definition
*b. six cardinal fields of gaze (CN III, IV and VI (visual acuity CNII) |
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Term
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Definition
*Verbalize equal and round |
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Term
VERBALIZE and demonstrate direct response |
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Definition
VERBALIZE and demonstrate consensual response |
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Term
*Accomodation and convergence |
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Definition
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Definition
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Definition
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Definition
*g. Fundocopic (verbalize red reflex, retina, vessels, optic disk) |
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Definition
*Inspect and palpate external ears |
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Term
b. gross hearing/whisper test (CN VIII) |
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Definition
*C. otoscopic ear canals. |
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Term
know what to note in ear canals |
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Definition
*e. Weber test (check for lateralization) |
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Term
*F. Rinne test. (Compares air and bone conduction) |
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Definition
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a. inspect and palpate external nose. |
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Definition
b. Patency of nostrils (CN I) |
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*c. Inspects nasal mucosa |
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Definition
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*a. Inspect lips and buccal mucosa with light and tongue blade. |
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Definition
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c. Tongue, CN XII (hypoglossal) |
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Definition
*Observe tongue at rest in the floor of the mouth |
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Term
*Observe tongue protruding. (CN IX and X) |
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Definition
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*Palpate tongue for strength against cheek |
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Definition
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Definition
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Definition
*G. Ask client to say "ah" and observe uvula movement (CN X-vagus) |
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Definition
a. Assess skin characteristics |
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Term
b. Inspect for symmetry, plus palpate for lumps and pulsations. |
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Definition
c. palpate and verbalize nodes |
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Definition
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Definition
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*superficial cervical nodes |
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Definition
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Term
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Definition
*Posterior cervical nodes |
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Definition
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*Auscultate and palpate carotic pulse. |
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Definition
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*e. palpate thyroid (front or back approach) |
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Definition
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*g. shrug shoulders against resistance (CN XI) |
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Definition
*h. Push chin against examiner's hand bilateral. |
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Term
D. Move to BACK of CLIENT, SITTING |
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Definition
CHEST AND LUNGS, POSTERIOR |
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Term
a. Inspect and VERBALIZE observations: |
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Definition
Thoracic cage configuration (AP and transverse diameter) |
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Definition
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*Retractions, heaves, or dyspnea |
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Definition
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The following criteria will be evaluated according to the competency map |
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Definition
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*c. palpate tactile fremitus |
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Definition
*d. percussion over lung fields |
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Term
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Definition
f. auscultate breath sounds with diaphragm of stethoscope in: |
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Term
Organized sequence, side to side. Posterior (6 minimum sites) |
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Definition
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Term
*g. Lateral breath sounds (5 sites) |
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Definition
h. describe breath sounds heard. |
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Term
*j. Assess for CVA tenderness |
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Definition
E. MOVE TO FRONT OF CLIENT. |
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Term
1. CHEST AND LUNGS, Anterior. |
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Definition
a. inspect and VERBALIZE observations |
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Definition
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b. Palpate for lumps or tenderness (4 places, upper/lower) |
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Definition
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Term
d. osculate breath sounds with diaphragm of stethoscope in organized sequence, side-to-side (4 minimum sites) VERBALIZE FINDINGS |
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Definition
F. CLIENT SUPINE, STAND AT CLIENT'S RIGHT. |
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Term
1. Heart (Pulls out table extension) |
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Definition
a. Inspect precordium for pulsations and heaves. |
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Term
b. Palpate precordium with palm. |
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Definition
*c. Locate, inspect, palpate, and auscultate PMI/apical impulse. |
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Term
*d. Auscultate apical rate and rhythm. Verbalize findings |
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Definition
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f. auscultates heart sounds in 5 areas with diphragm |
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Definition
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Definition
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Definition
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g. Auscultate heart sounds in 5 areas with bellL |
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Definition
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Definition
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Definition
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Definition
a. Ensures out/pulls out table extension |
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Term
b. observe abdomen at eye level from client's right |
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Definition
c. inspect skin characteristics |
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Term
d. inspect contour, symmetry |
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Definition
e. inspect umbilicus and pulsations |
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Term
f. ask client to raise head. |
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Definition
g. observe face while client has head raised. |
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Term
h. observe abdomen while client has head raised. |
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Definition
*auscultate bowel sounds with diaphragm in all four quadrants |
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Term
*auscultate bowel sounds with diaphragm in all four quadrants |
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Definition
*auscultate vascular sounds with bell (5 sites) |
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Term
*j Percuss in all four quadrants. |
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Definition
*k. light palpation in all 4 quadrants |
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Term
*l. Deep palpation in all 4 quadrants. |
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Definition
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Definition
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Definition
b. inspect skin characteristics, hair distribution |
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Term
*palpate and auscultate femoral pulse |
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Definition
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Term
*f. Posterior tibial pulses VERBALIZE findings on 0- +4 scale |
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Definition
*g. Dorsalis pedis pulses. VERBALIZE findings on 0-+4 scale |
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Term
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Definition
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Term
*j. Range of motion, hips |
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Definition
*k. range of motion, knees |
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Term
*l. muscle strength, hips |
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Definition
*m. muscle strength, knees |
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Term
n. heel down shin bilateral |
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Definition
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Definition
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Definition
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Definition
a. walks across room (gait) |
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Definition
c. walk on tiptoes, then walk on heels |
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Definition
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Definition
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*curvatures (cervical, thoracic, and lumbar) |
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Definition
*from behind for lateral curvatures, inequality of scapula, iliac crests and gluteal folds |
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Definition
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