Physical Assessment

My name is _______ and I will assess the following patient.

Appears stated age:

GENERAL SURVEY OF PATIENT

Level of consciousness
“Appears alert, conscious, and oriented x 3 (person, place, time)”
What is your name?
Where are we?
What is the current month?
Nutritional Status
“Appears adequately nourished”

Symmetry, Posture and Position

“Body parts look equal bilaterally and are in relative proportion to each
other”
“Person stands comfortably erect as appropriate for age”
“Person seems comfortable and relaxed on exam table”

Obvious Physical Deformities

“No obvious physical deformities”

Mobility: gait, use of assistive devices

“Gait is normal with base as wide as the shoulder width. Foot
placement is accurate; the walk is smooth, even and well-balance.
Symmetrical arm swinging is present; Range of movement is deliberate,
accurate, smooth and coordinated with no involuntary movement”

Facial Expression
“Patient maintains eye contact and expressions are appropriate to the
situation”

Mood and affect

“Patient is comfortable and cooperative and interacts pleasantly”

Speech: articulate, pattern, content appropriate, native language

“Articulation is clear and understandable. The stream of talking is
fluent with an even pace. The person can conveys ideas clearly; word choice
is appropriate; communicates clearly”

Hearing
“Patient verbalizes and responds to questions to appropriately”

Personal hygiene

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 Physical Assessment

“Dress is appropriate to season and climate; person appears clean and

groomed appropriately for his age, occupation, and socioeconomic group”
MEASUREMENT AND VITAL SIGNS
Height _____________ Weight _______
Snellen Chart (CN II)
Right Eye_________ Left Eye_________
Temperature
BP
Pulse
Respirations
Pain Assessment

SKIN
Hands and nails
“Skin is uniform in color with pinkish undertones, warm and dry to
touch, smooth with no lesions, scars, birthmarks, wounds present”
“Capillary refill less than 3 seconds”
Skin Turgor
“Skin quickly returns to normal upon being pinched up”

Color and Pigmentation

“Skin is uniform in color with pinkish undertones, smooth, with no
lesions, scars, birthmarks, or wounds present”

Temperature
“Skin is warm to the touch, equal and bilaterally”

Moisture
“Skin is adequately moisturized”

Texture
“Skin feels smooth and firm with an even surface; no lesions present”

Any Lesions
“No visible lesions”

Cranial Nerves
I. Olfactory sensory = sensory smell
Present patient with cinnamon or alcohol

II. Optic sensory = sensory vision

Snellen chart
Visual fields, confrontation test

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III. Oculomotor = motor eye movement (inward & upward & downward
eyelid movement, pupil constriction, convergence, consensual
reaction
Cardinal positions of gaze

IV. Trochlear = motor eye movement downward inward

Cardinal positions of gaze

V. Trigeminal motor/sensory = chewing, sensations of the face, scalp,

and teeth
Clench teeth
Light touch sensation

VI. Abducens motor = lateral eye movement

Cardinal positions of gaze

VII. Facial motor/sensory = facial expressions, taste (anterior 2/3 of

tongue)
Smile, frown, close eyes tightly, lift eyebrows, show teeth, puff
cheeks

VIII. Vestibulartrochealer sensory = hearing & equilibrium

Whisper test: ability to hear high pitch sound
Weber test :bone conduction
Rinne test: AC > BC

IX. Glossopharyngeal motor/sensory = swallowing, salivation,

sensations of throat & tonsils, posterior 1/3 of tongue
Use tongue blade to test gag reflex

X. Vagus motor = motor/sensory swallowing, talking, heart rate,

peristalsis sensations of throat & tonsils
Uvula rises midline
Have patients say “Ahhhh”
Use tongue blade to test gag reflex

XI. Spinal accessory motor = shoulder movement, head rotation

Shoulder shrug

XII. Hypoglosssal motor = tongue movement

Have patient stick out tongue—should protrude down the midline

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 Physical Assessment

Temporomandibular
“Normally smooth movement with no limitation or tenderness”
Palpate the joint as the person opens the mouth

ROM and muscle strength

“Full ROM with no pain; movement is smooth and controlled;
demonstrates adequate muscle strength”
Ask patient to touch chin to chest, turn head to the right and left,
try to touch each ear to the shoulder (without elevating shoulders), and to
extend the head backward

CN XI: shoulder shrug

Completed in above examination of cranial nerves

UPPER EXTREMITIES
Symmetry
“Joints and muscles symmetric”

Skin characteristics
“Skin color is consistent with patient’s genetic background; no lesions”

ROM (active, passive)

Shoulder
“Full ROM, movement smooth, no crepitance, no tenderness”
Have patient perform 4 motions: see pages 615-616 for
descriptions and demonstrations: (1) with arms at sides and elbows
extended, move both arms forward and up in wide vertical arcs, then move
them back; (2) rotate arms internally behind back, place back of hands as
high as possible toward the scapulae; (3) with arms at sides and elbows
extended, raise both arms in wide arcs in the coronal plane, touch palms
together above head; (4) touch both hands behind the head with elbows
flexed and rotated posteriorly
Elbow
“Full ROM, movement smooth, no crepitance, no tenderness”
Have patient perform 2 motions: (1) bend and straighten
the elbow; (2) movement of 90 degrees in pronation and supination
Wrist and hand
“Full ROM, movement smooth, no crepitance, no tenderness”
Six motions: (1) bend the hand up at the wrist; (2) bend
hand down at the wrist; (3) bend the fingers up and down at
metacarpophalangeal joints; (4) with palms flat on table, turn them outward

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and in; (5) spread fingers apart, make a fist; (6) touch the thumb to each
finger and to the base of little finger

Muscle strength (0-5)

“Muscle strength—able to maintain flexion against resistance and
without tenderness. Muscle strength is a 5 on scale”
(1) Test strength of shoulder muscle by asking the person to
shrug the shoulders, flex forward and up, and abduct against your
resistance; (2) Test strength of elbow (???) by stabilizing the person’s arm
with one hand and have the person flex the elbow against your resistance
applied just proximal to the wrist, and then ask the person to extend the
elbow against your resistance; (3) Test strength of wrist and hand by
positioning the person’s forearm supinated and resting on a table, stabilize
by holding your hand at the person’s midforearm, and ask the person to flex
the wrist against your resistance at the palm

Joint tenderness
“No tenderness to palpation of joints; no heat, swelling, or masses”

DTR (Deep Tendon Reflex)

*** Triceps
“DTR 2+ and equal bilaterally”
Tell the person to relax arm as you suspend it by holding
the upper arm. Strike the triceps tendon directly just above the elbow.
Forearm should extend.

Peripheral pulses (0-3+)

Radial
“Pulse present, 2+ and equal bilaterally”

Ulnar
“Pulse present, 2+ and equal bilaterally”

Brachial
“Pulse present, 2+ and equal bilaterally”

Epitrochlear nodes
“Lymph nodes are movable, discrete, soft, and not tender”
Check the epitrochlear lymph node in the depression above and
behind the medial condyle of the humerus. Do this by “shaking hands” with
the person and reaching your other hand under the person’s elbow to the
groove between the biceps and triceps muscles, above the medial
epicondyle—shouldn’t be palpable

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 Physical Assessment

BREASTS (SITTING)
Symmetry
“Breasts are symmetrical; skin smooth with even color and no rash or
lesions”
Accessed via inspection; slight asymmetry is normal (with left
usually larger)

Dimpling
“Arm movement shows no dimpling or retractions”

BREASTS (Patient supine, stand at patient right)

Breast palpation
“Breast contour and consistency firm and homogenous; no masses or
tenderness; no lymphadenopathy”
Have patient lie down and raise one arm at a time above head.
Use the pads of your first three fingers and make gentle rotary motion on the
breast (see p. 421 for demo)

Nipple
“No nipple discharge”
“Nipples are symmetrically placed on the same plane”
Palpate the nipple; with thumb and forefinger, gently depress the
nipple tissue into the well behind the areola (tissue should move inward
easily)

Axilla
“Nodes are not enlarged or tender”
Lift the woman’s arm and support it yourself, so that the muscles
are loose and relaxed. Move in four directions: (1) down the chest wall in a
line from the middle of the axilla, (2) along the anterior border of the axilla,
(3) along the posterior border, (4) along the inner aspect of the upper arm.
Move arm through ROM to increase the surface area you can reach.

HEART/NECK VESSELS
Jugular vein distention
“Internal jugular vein pulsations present when supine, and disappear
when elevated to a 45 degree position; no distention”

Precordium: pulsations, heave, thrill

“Inspection. No visible pulsations, no heave or lift”
Using the palmar aspects of your four fingers, gently palpate the
apex, the left sternal border, and the base, searching for any other

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pulsations.

Apical impulse
“Apical pulse in 5th ics at left midclavicular line, no thrill”

Apical pulse rate and rhythm

“Normal pulse rate 60-80 bpm. Rhythm regular”
Listen at apical for 1 minute

Heart sounds
Ausculatory areas
“S1 and S2 are normal, not diminished or accentuated, no S3 or
S4 or other extra sounds, no murmurs”
Listen with diaphragm and bell of stethoscope
See page 503 for areas to auscultate

ABDOMEN
Contour, symmetry
“Abdomen flat, symmetric with no apparent masses”
Stand on person’s right side and look down on the abdomen.
Then stoop or sit to gaze across the abdomen. Your head should be slightly
higher than the abdomen. Determine the profile from the rib margin to the
pubic bone. The contour describes the nutritional state and normally ranges
from flat to rounded.
Shine a light across the abdomen toward you, or shine it
lengthwise across the person. The abdomen should be symmetric bilaterally.
Step to the foot of the examination table to recheck symmetry. Ask the
person to take a deep breath to further highlight any change. The abdomen
should stay smooth and symmetric. Or ask the person to perform a sit-up
without pushing up with their hands.

Skin characteristics
“Skin smooth with no striae, scars, or lesions”

Bowel sounds
“Bowel sounds present; no bruits”
Begin in the right lower quadrant at the ileocecal valve area
because bowel sounds are normally always present here.

Light palpation
“Abdomen soft, no organomegaly, no masses, no tenderness”
Light versus deep palpation

 Listen for bruit if you see pulsating in abdomen

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 Physical Assessment

INGUINAL AREA
Femoral pulse
*** “Femoral pulse 1+”
Femoral pulse is located just below the inguinal ligament halfway
between the pubis and anterior superior iliac spines

Inguinal nodes
“Lymph nodes are movable, discrete, soft, and not tender”

LOWER EXTREMITIES
Symmetry
“Joints and muscles symmetric”

Skin characteristics
“Skin color is consistent with patient’s genetic background; no lesions”

ROM (active, passive)

Hip
“Full ROM, movement smooth, no crepitance, no tenderness”
Motions: (1) raise each leg with knee extended; (2) bend
each knee up to the chest while keeping the other leg straight; (3) flex knee
and hip to 90 degrees. Stabilize by holding the thigh with one hand and the
ankle with the other hand. Swing the foot outward. Swing the foot inward. (4)
Swing leg laterally, then medially, with knee straight. Stabilize pelvis by
pushing down on the opposite anterior superior iliac spine. (5) When
standing, swing straight leg back behind body. Stabilize pelvis to eliminate
exaggerated lumbar lordosis. The most efficient way is to ask person to bend
over the table and to support the trunk on the table. Or the person can lie
prone on the table.

Knee
“Full ROM, movement smooth, no crepitance, no tenderness”
Motions: (1) bend each knee; (2) extend each knee; (3)
check knee ROM during ambulation

Ankle
“Full ROM, movement smooth, no crepitance, no tenderness”
Motions: (1) point toes toward the floor; (2) point toes
toward your nose; (3) turn soles of feet out, then in; (4) flex and straighten
toes

Muscle strength (0-5)

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“Muscle strength—able to maintain flexion against resistance and

without tenderness. Muscle strength is a 5 on scale”
Check muscle strength by asking the person to maintain knee
flexion while you oppose by trying to pull the leg forward. Muscle extension
is demonstrated by the person’s success in rising from a seated position in a
low chair or by rising from a squat without using the hands for support.
Check muscle strength in wrist and feet by asking the person to maintain
dorsiflexion and plantar flexion against your resistance.

Joint tenderness
“No tenderness to palpation of joints; no heat, swelling, or masses”

Peripheral pulses
Popliteal
“Popliteal both 0”
Posterior tibial
“Both 0 but present with doppler”
Dorsalis pedis
“Zero but left dorsalis pedis is present with Doppler; right is not
present with doppler”

Pretibial edema (pitting 1-4 scale)

“No pitting edema present; 0 on scale”
Firmly depress the skin over the tibia or the medial malleolus for
5 seconds and release.

Homan’s sign
“Negative Homan’s sign”
Flex the person’s knee, then gently compress the calf muscle
anteriorly against the tibial; no tenderness should be present. Or you may
sharply dorsiflex the foot toward the tibia. Flexing the knee first exerts
pressure on the posterior tibial vein. Should not cause pain.

Capillary refill
“Capillary refill less than 3 seconds”

DTR
Patellar reflex
“DTR 2+ and equal bilaterally”
Let the lower legs dangle freely to flex the knee and
stretch the tendons. Strike the tendon directly just below the patella.
Extension of the lower leg is the expected response.

Inspect, palpate, auscultate (format you follow)

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Do this for every body region (except GI)

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