Physical Examination/Assessment

General Skills (8 pts.)

Gather needed equipment prior to the exam. Wash hands
Good afternoon, my name is Keirvy, Im a student nurse here at UNLV, and Ill be doing your assessment today.
Subjective Data (7pts)
What brings you in today?
1. Do you have any chronic illnesses? (DM or HTN?)
2. Are your immunizations up to date? (Flu shot? Tetanus?)
3. When was your last physical exam?
Do you have a family history of any illnesses or diseases? (DM or HTN?) If yes, how is this treated?
Do you have any allergies? (PCN?) If yes, what is your reaction?
Are you taking any medications, including vitamins, supplements, OTC?
Objective Data (5pts)
Observe general appearance of client:
I have a female patient appears stated age. She is awake, alert, cooperative, and responsive. Appears well nourished, well hydrated,
with no obvious deformities. Sitting upright on the exam table, mood is calm, and speech is articulate
Skin
Note throughout exam (points assigned in EACH section)
Head & Face (12 pts.)
Can you smile for me? Frown? Puff out your cheeks?
Facial expressions are symmetrical. CN 7 intact. Skin intact, no lesions.
Inspect and palpate scalp:
No Lesions, no inhabitants
Hair is ______ color, smooth, and evenly distributed
Inspect cranium. Cranium is normocephalic
Palpate temporal pulses. Temporal pulse is 2+ equal bilaterally
Palpate maxillary and frontal sinuses. Ask patient if feeling any pressure or pain?
No pressure or pain to palpation of frontal and maxillary sinuses
Palpate patients TMJ and ask:
Can you open your mouth, close, side to side, protract (forward) your jaw for me? Retract (back)? Any pain?
TMJ has full range of motion. No popping, clicking, heat, or tenderness noted upon palpation of the TMJ. CN 5 intact
Ears (3 pts.)
Inspect external ear. No drainage or lesions noted bilaterally
Palpate auricle. No tenderness of the auricle upon palpation bilaterally.
Whisper voice test: ask patient to occlude tragus bilaterally and whisper: 1st word: Apple, 2nd word: Fourteen
Patient identifies 2 syllable words at 2 feet distance bilaterally. CN 8 intact
Eyes (13 pts.)
Inspect and palpate eyelids: Palpebral fissures are intact with No ptosis or drooping noted, CN 3 intact
Inspect lacrimal apparatus: No drainage or tenderness of lacrimal apparatus
Inspect conjunctiva: Conjunctivas are pink, smooth, and moist bilaterally
Inspect sclera: Sclera are smooth, white, and moist. No lesions or discharge noted bilaterally
Hand patient near vision card and ask to cover each eye and read lowest line possible, then read with both. Ask if wearing contacts.
20/20 vision in right, left, and both eyes using near vision test CN 2 intact (correction, errors if applicable)
Ask patient to cover one eye, make sure at eye level. Look directly into examiners eye and say now when sees finger tips.
Patients peripheral vision equal to examiners with confrontation test, CN 2 intact
Have patient cover one eye with index card and look at the cupboard. Have remove card and note gaze, do on both sides.
Steady fixed gaze with cover/uncover test, CN 3, 4, and 6 intact
Diagnostic positions test: without moving your head please follow my fingers with your eyes. EOM intact with no nystagmus or
darting noted CN 3, 4, and 6 Intact
*Pen light* shine light into each pupil twice. Have patient look at wall, then finger. Compare pupils to chart for size.
Pupils are _____ size, equal, round, reactive to light - direct and consensual, accommodation CN 3,4, and 6 intact
Direct patient to look over shoulder. Shine light in eyes about 14 inches away and note reflection. Negative Hirschberg test.
Nose (6 pts.)

Inspect nose for symmetry. Nose is midline with no redness, swelling, lesions or drainage noted.
With pen light or otoscope look into patients nose. Nasal Mucosa is pink and moist bilaterally with no septal deviation or lesions
noted
Can you please close your eyes? Im going to have you identify some scents. Please occlude your L/R naris and tell me what you
smell. Nares are patent bilaterally. Patient correctly identified scent in each naris, CN 1 intact
Mouth and Throat (12 pts.)
Inspect lips. Lips are pink and moist, no dropping noted.
With pen light/otoscope and tongue depressor, look inside mouth. Buccal mucosa is pink and moist. No lesions noted
Teeth are white and aligned, no dental carries noted. Gums are pink with no lesions or bleeding noted.
Ask patient to stick out their tongue. Tongue protrudes midline. CN 12 intact
Lift your tongue up? Inspect roof of mouth. No lesions or white patches on the floor of the mouth. Hard and soft palates are intact
Ask patient to open your mouth? Say Ahh? Uvula rises midline on the phonation of Ahh. CN 9 and 10 intact
Have you had your tonsils removed? Tonsils are intact and +1 bilaterally or tonsils not present.
Note breath or odor. No Halitosis noted
Ok Im going to be checking your gag reflex now. Place tongue depressor on tongue. Gag reflex present. CN 9 intact
*Dispose of tongue depressor in garbage
Can you please close your eyes? Im going to place a food item in you hand. Please place it in your mouth and tell me what it tastes
like (Patient only has to identify if the flavor of the candy or that its a sweet candy). Patient is able to identify taste. CN 7 intact
Neck (19 pts.)
Inspect neck. Neck is symmetrical.
Palpate lymph nodes with finger tips using a circular motion. State lymph node name as palpate.
Preauricular, Posterior auricular, Occipital, Submental, Submandibular, Tonsillar, Superficial cervical (Overlying the sternomastoid
muscle) Deep cervical Deep (under the sternomastoid muscle), Posterior cervical (Along the trapezius muscle), Supraclavicular, Infraclavicular
No lymphadenopathy
Inspect and palpate trachea. Trachea is midline
Go behind or front of the patient and deviate the trachea and palpate for the thyroid gland as the patient is swallowing on both sides
Thyroid glands are non-palpable
ROM: Flexion/Extension -Tilt your head front/back, Lateral Bend - Side to side, Rotation - Rotate L/R, Shoulder shrug (elevation) Shrug your shoulders up
Put downward resistance while patient shrugs up, go against me. Place hand on each side of patients head, go against me. Place
hand on front/back of patients head, go against me.
Full active ROM of the neck. Muscle strength right equals left, flexion equals extension. CN 11 intact
Posterior Thorax (6 pts.)
Inspect skin. Skin intact, no lesions, warm to touch
Palpate for symmetric thoracic expansion, ask patient to take deep breath in and out. Symmetrical chest expansion of posterior thorax
Im going to place my palms on your back and every time I place them, please say 99. Symmetrical tactile fremitus on posterior and
lateral thorax bilaterally
Percuss posterior and lateral lung fields. Posterior and lateral lung fields percuss resonance bilaterally.
Patient is sitting up while you stand behind them and place one hand over the twelfth rib at the costovertebral angle on the back.
Thump that hand with the ulnar edge of your other fist, ask if pain? No CVA tenderness bilaterally
Auscultate lung sounds posteriorly and laterally. Posterior and lateral lung sounds clear to auscultation with no adventitious sounds
bilaterally
Anterior Thorax (7 pts.)
Inspect configuration of anterior chest. No barrel chest
Inspect skin on anterior chest. Skin is pink, no lesions, smooth, dry, warm to touch
Skin turgor test at collar bone bilaterally. Skin turgor returns to base line in less than two seconds
Palpate anterior chest for symmetrical expansion. Ask patient to take deep breath in and out. Symmetrical chest expansion of anterior
thorax
Im going to place my palms on your back and every time I place them, please say 99.
Symmetrical tactile fremitus on anterior thorax bilaterally
Percuss anterior lung fields. Anterior lung fields percuss resonance bilaterally
Auscultate breath/lung sounds anteriorly and laterally. Anterior and lateral lung sounds clear to auscultation with no adventitious
sounds bilaterally.
Heart (Upright Position) (10 pts.)
Auscultate lung sounds with diaphragm and patient sitting it upright position. Aortic 2nd intercostal space, right sternal border,
Pulmonic 2nd intercostal space, left sternal border, Erb's point 3rd intercostal space, left sternal border, Tricuspid 4th intercostal

space, left sternal border, Mitral 5th intercostal space, left midclavicular line
Auscultate heart sounds with bell in reverse order. Mitral, Tricuspid, Erb's point, Pulmonic, Aortic
S1, S2 present. No S3, S4 or murmurs on all 5 precordial sites upon auscultation using the diaphragm and bell of stethoscope while
patient is sitting in the upright position
Breasts (10 pts.)
Place breast simulator on patient. Inspect breasts for symmetry with patient in upright position.
Females: have patient place arms overhead, on hips, and hands pressed in front of body.
Female: Breasts are symmetrical with no lesions or rashes noted. Movement is symmetrical with no dimpling or retractions noted.
Move patient into supine position on exam table. Slide leg support out. Place patient arm over head and examine one breast at a time.
Explain method of ideal breast exam while conducting (Spokes on a wheel and concentric circles). Include each breast, tail of spence,
and axillary region, most masses are found in these areas. Inform patient that ideal breast exam should be conducted 4-7 days after
menstrual cycle each month. Warn patient, and complete nipple discharge test.
No lumps, masses, tenderness, or nipple discharge noted bilaterally.
Remove breast simulator, keep patient in supine position.
Males: assess chest wall in upright position with arms at their sides. Note skin surface and any swelling.
Male: skin on chest is smooth, dry, and warm to touch. No lesions, swelling, or redness noted.
Palpate for any lumps/masses or tissue enlargements on chest (over the tshirt). Discuss education with patient, male breast cancer is
rare, about 1% of breast cancers. Males are often diagnosed later in the disease process so its important to note changes and follow
up with your primary care provider. Have you noticed any nipple discharge? Any masses or other changes in your chest?
No lumps, masses, or tissue enlargements on chest. No lymphadenopathy in axillae.
Heart (Supine) (18 pts.)
While patient is in supine position, inspect precordium for heaves, lifts, or pulsations.
No visible lifts, heaves, or pulsations upon inspection of anterior chest
Palpate the carotid pulse one side at a time (Medial to the sternomastoid muscle in the neck).
Carotid pulse 2+ equal bilaterally
Palpate the precordium for palpable murmurs using palmar aspect of your 4 fingers to palpate the actual sites (aortic, pulmonic,
Erbs point, tricuspid, mitral). No palpable thrills noted.
Palpate the apical impulse and note location.
Apical pulse is nonpalpable at the 5th intercostal space left midclavicular line.
Auscultate the carotid arteries for bruits with the bell of the diaphragm.
No bruits auscultated to carotid arteries bilaterally
Auscultate heart sounds with diaphragm of stethoscope and patient in supine position. Aortic, Pulmonic, Erb's point, Tricuspid, Mitral
Auscultate apical heart rate for 30 seconds. Apical HR ____ beats per minute, Regular rhythm
Auscultate heart sounds with bell (going reverse order from Mitral Aortic); Mitral, Tricuspid, Erb's point, Pulmonic, Aortic
S1, S2 heard. No S3, S4 or murmurs on all 5 precordial sites upon auscultation using the diaphragm and bell side of stethoscope with
patient in a supine position
Abdomen (8 pts.)
Inspect abdomen for contour, umbilicus, and skin characteristics.
Abdomen is flat; umbilicus is midline and inverted. Skin is smooth dry warm to touch. No lesions noted.
Auscultate for bowel sounds x 4 quadrants. Bowel sounds are normoactive in all 4 quadrants
Inform patient will palpate abdomen to let me know if feel any pain. Light palpation, ask for pain. Deep palpation, ask for pain. Right
side complete hepatomegaly test (patient breath in and out). Left side complete splenomegaly test (patient breath in and out).
Abdomen is nontender upon light and deep palpations no masses noted. No hepatomegaly, or splenomegaly.
Lower Extremities (22 pts.) Maintain privacy
Inspect and Palpate skin on legs for symmetry, temperature, lesions, hair distribution, or redness, swelling, pain, or deformities.
Legs are symmetrical, nontender to palpation, hair is evenly distributed throughout. They are smooth, dry, and warm to touch. No
redness, swelling, or deformities noted.
Check each leg for pitting edema. No Edema noted bilaterally.
Palpate popliteal pulse, dorsalis Pedis pulse, posterior tibialis pulse
Popliteal pulse +1 equal bilaterally; Dorsalis pedis and posterior tibialis pulses are +2 equal bilaterally.
Im going to look at your range of motion in your lower body and Ill be walking you through each test. Be aware of patient privacy,
can you please flex your leg at the hip, now extend back, abduct it out towards me, adduct it back in, rotate internally, now externally.
Now the other side flex, extend, abduct, adduct, internal rotation, and external rotation. Im going to look at your muscle strength and
just comparing the right to the left side, ok? Place hand above knee, youre going to push against my hand for flexion, extension go
against me, abduction go against me, and adduction go against me. Now for the other side flexion, extension, abduction, and
adduction.
Sit patient up on exam table and slide leg support in. Can you please extend your leg out at the knee, now flex it back. Both knees at

same time and hand below knee. Ok great, now go against me for extension, go against me for flexion.
Can you point your toes toward the ceiling for dorsiflexion, now point your toes to the floor for plantar flexion. Rotate them in for
inversion, now rotate them out for eversion. Now around the world for rotation at your ankles. Place hand on top of each foot, go
against me for dorsiflexion, go against me for plantar flexion.
Can you flex just your toes up to the ceiling, and can you try and fan your toes out for abduction?
Full active ROM (after each joint). Muscle strength right equals left.
Using a reflex hammer, draw a light stroke up the lateral side of the sole of the foot and inward across the ball of the foot, like an
upside-down J to test for plantar reflex/Babinski. Negative Babinski.
Upper Extremities (21 pts.)
Inspect and palpate symmetry, skin characteristics, temperature, redness, pain, swelling, deformities.
Upper extremities symmetrical, no lesions, warm to touch, no redness, pain/swelling, or deformities noted
Inspect nail bed color, shape, and angle. Nail beds are pink with no clubbing noted, bilaterally
Check capillary refill bilaterally. Capillary refill returns to baseline in less than 2 seconds bilaterally
Palpate radial pulse and brachial pulse. Radial and brachial pulses are +2 equal bilaterally
Im going to look at your range of motion in your upper body now. Ill demonstrate for you as we go. Can you please flex at your
shoulders, extend, hyperextend? Now abduct, circumduction, adduct, internally rotate, and externally rotate.
Im going to look at your muscle strength on each side, please go against me for flexion, extension, abduction, and adduction on right
and left sides.
Can you flex at the elbow, now extend. And go against me for flexion, and against me for extension on each side concurrently.
Please flex your wrists, now extend, pronate, supinate, radial deviation, ulnar deviation, and rotation. Now go against me for flexion,
and extension each side concurrently.
Last one, can you flex your fingers, extend your fingers. Now grasp my fingers and squeeze.
Full active ROM on upper extremities. Muscle strength right equals left. Finger grasp equal bilaterally.
Neurologic (10 pts.)
Please close your eyes and hold your hands with the palms facing up. Im going to trace a number in each palm, can you please
identify the number? Graphesthesia is intact
With your eyes remaining closed, Im going to place an object in each hand. Can you please identify the object?
Stereognosis is intact
Now with you eyes open please do a patty cake like this with your hands on your legs alternating sides as fast as you can.
Rapid alternating movements are smooth and coordinated bilaterally
Ok we are going to look at some sensory identification on your skin. Break a tongue depressor. Please close your eyes, this is the dull
pain and this is the sharp pain, ok? Test two sites on each side including hands and feet.
Superficial pain sensation is intact.
Ok with you eyes closed Im going to lightly touch your face and extremities. Just say now when you feel the sensation.
Light touch sensation intact. CN 5 intact
Ok we are going to look at your deep tendon reflexes. Check both sides (bilateral). Must name the reflex, grade the reflex 0-4 [0: no
response, 2+: Normal, 4+: Hyperactive]. Biceps deep reflex Place your thumb on the biceps tendon and strike a blow on your thumb.
Triceps deep reflex Strike the triceps tendon directly just above the elbow. Brachioradialis deep reflex Hold the person's thumbs and
strike the forearm directly, about 2 to 3 cm above the radial styloid process. Patellar deep reflex (Strike the tendon directly just below
the patella). Achilles deep reflex (Dorsiflex the foot, and tap the tendon)
_____________ deep reflex is +2 bilaterally after each test.
If you cant find the reflex after the first time trying, state: Unable to elicit reflex in the (location) (name)
Musculoskeletal (11 pts.)
Have patient stand up (make sure gown is secure when bending forward). While patient standing inspect shoulder symmetry and
scapula symmetry.
Shoulders and scapula are symmetrical.
Ok, please bend forward like youre diving into a pool, ensure gown is secured to patients back. Note symmetry of back and
elevations. Palpate spinous processes.
Shoulders and scapula are symmetrical in bending position with no prominences or elevations noted. Spinous processes are aligned.
Have patient stand back up. We are going to do a few more range of motion tests, but for your spine this time. Ill demonstrate for you
as we go. Can you flex forward, stand up tall for extension, bend back for hyperextension, lateral flexion, lateral flexion, now rotation.
Full active ROM in spine
Alright, now can you please take five steps toward the door. Now walk back toward me walking heel to toe. Walk toward the door on
just your toes. Now back toward me on just your heels.
Gait is steady and coordinated
This is the last test we are going to do today. Im going to have you stand here with your eyes closed for 20 seconds.
Negative Romberg.
My assessment is complete. Thank you!

Poin
ts

Time
Used

End
Time

1. General Skills
2. Subjective
Data
3. Objective Data
4. Head & Face
5. Ears
6. Eyes
7. Nose
8. Mouth & throat
9. Neck
10. Posterior
Thorax
11. Anterior
Thorax
12. Heart
(upright)
13. Breast
14. Heart (supine)
15. Abdomen
16. Lower
Extremities
17. Upper
Extremities
18. Neurologic
19.
Musculoskeletal
20. Skin (5

8
7
5
12
3
13
6
12
19
6
7
10
9
18
8
22
21
10
11

throughout)

Remaining