CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT SKIN, HAIR AND NAIL Skin pink, warm, dry and and elastic. No lesions or excoriations excori ations noted. Old appendecto appendectomy my scar right lower abdomen 4 inches long, thin, and and white. white. Sprinkling of freckles freckle s noted across cheeks and and nose. nose. Hair brown, shoulder length, clean, shiny. Normal distribution of of hair on scalp and perineum. perineu m. Hair has been removed form legs, axillae. axillae. Nails form 160 degree angle at base, are hard, smooth, and and immobile. Nailbeds pink without clubbing. Cuticles smooth, no detachment detachme nt of of nailplate. Hands well manicur manicured ed with clear enamel. HEAD AND NECK Head symmetrically symmetric ally round, hard, hard, and smooth without lesions or bumps. Face oval, smooth, and symmetrical. symmetri cal. Temporal artery elastic and nontender. Temporomandibular joint palpated with full range of motion motion without tenderness. Neck symmetric with centered head position and no bulging bulging masses. C7 is visible and palpable with neck flexion. Has smooth, controlled, full range range of motion of neck. Thyroid gland gland nonvisible but palpable when swallowing. swallowi ng. Trachea in midline. Lymph nodes nonpalpable. EYE AND EAR Acuity by Snellen chart O.D. 20/20, O.S. 20/20. Visual fields full by confrontation. confrontatio n. Extraocular Extraoc ular movements smooth and and symmetric with no nystagmus. Evelids in normal position with no abnormal widening or ptosis. No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera scler a appear moist and smooth. Sclera white with no lesions or redness. No swelling swelli ng or redness over lacrimal gland. Cornea is transparent, smooth, and moist with no no opacities, lens is free of opacities. Irises are round, round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. accommodati on. Pupils converge evenly. Ears are equal in size bilaterally. Auricles are aligned with the corner of each eac h eye. Skin smooth, no lumps, lesions, nodules. nodules. No discharge. Nontender on on palpation. Small amount of moist yellow cerumen cerume n in external canal. Whisper test : patient repeats repeat s 2 syllable word. MOUTH, THROAT, NOSE, AND SINUS Lips pink, pink, smooth, and and moist without without lesions. Buccal mucosa pink, moist, moist, and without without exudates. Stensen/s ducts visible with no redness or swelling. swelli ng. 32 white white to yellowish teeth present. Gums pink without redness or swelling. swelli ng. Protrudes geographic tongue in midline midline with no no tremors. Equal bilateral strength in tongue. Ventral surface of tongue smooth and shiny pink with small visible veins present. Frenulum in midline. Soft palate smooth and pink. Tonsillar pillars pink and symmetric symmetri c . Nose somewhat large but but smooth and symmetric. symmetri c. Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does does not obstruct obstruct airflow. Inferior and middle middle turbinates dark pink pink,, moist, and free of lesions. No purulent drainage noted. Frontal and and maxillary sinuses are nontender nontender to palpation and percussion. percussi on. THORAX AND LUNG Respirations Respirat ions 18/minute, relaxed and even. Anteroposterior Anteropost erior less than transverse diameter. Chest expansion symmetric. No retraction retrac tion or bulging of interspaces. interspace s. No pain or tenderness tendernes s on palpation. Tactile Tactil e fremitus symmetric. Percussion Percussi on tones resonant over all lung fields. Vesicular breath sounds auscultate auscultated d over lung lung fields. fields. No adventitious adventitious sounds present. BREASTS AND LYMPHACIC Bilateral Bilater al breasts moderate in size, pendulant, and and symmetric. Breast skin pale, pink with light brown areola. Nipples everted bilaterally. bilater ally. Free movement of breasts with position changes of arms and hands. No dimpling, dimpling, retraction, retrac tion, lesions, or inflammation noted. Axillae free of rashes or inflammation.
No masses or tenderness noted on palpation. Bilateral mammary ridge present. No discharge noted from nipples. Axillary ( central, posterior, or anterior) and lateral arm lymph nodes nonpalpable. Demonstrates appropriate technique for BSE. HEART AND NECK VESSELS Carotid pulse equal bilaterally, 2+, elastic. No bruits auscultated over carotids. Jugular venous pulsation disappears when upright. Apical impulse palpated in the fifth ICS at the left MCL. Apical pulse- 70 beats/minute, regular rhythm, S1 heard best at the apex, S2 heard best at the base.
ABDOMEN Skin of abdomen is free of striae, scars, lesions, or rashes. Umbilicus is midline and recessed with no bulging. Abdomen is flat and symmetric with no bulges or lumps. No bulges noted when patient raises head. No peristaltic movements seen. Soft clicks and gurgles heard at a rate of 15 per minute. Percussion reveals generalized tympany over all four quadrants. No tenderness or guarding in any quadrant with light palpation. Umbilicus and surrounding area free of masses, swelling, and bulges. MALE GENITALIA pubic hair growth pattern is normal for adult male: pubic hair and base of penis are free of excoriation and infestation. Circumcised penis is free of rashes, lesions, and lumps and is soft, flaccid and nontender on palpation. Glans is rounded, and free of lesions; urinary meatus is centrally located on glans; no discharge is palpated from urinary meatus. No masses or swelling noted in scrotum and left side hangs slightly lower than right side. Skin is free of lesions and appears rugated and darkly pigmented. Two descended testicles palpated. No swelling, tenderness,or masses palpated along the testicle. No bulges or masses palpated in inguinal or femoral canal. FEMALE GENITALIA Normal hair distribution, no lesions, masses, or swelling. Labia majora pink, smooth, and free of lesions, excoriation, and swelling. Lania minora dark pink, moist, and free of lesions, excoriation, swelling or discharge. No discharge from urethral opening. No malodorous discharge noted from vagina. ANUS AND RECTUM The anal opening is hairless, moist, and closed tightly. Perinanal area is free of redness, lumps, ulcers, lesions, and rashes. No bulging of lesions appear when the patient performs the Valsalva maneuver. Patient can close external sphincter around gloved finger. Anus is smooth, nontender, and free of nodules and hardness. PERIPHERAL VASCULAR arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally. Capillary refill time less than 2 seconds, radial and brachial pulses strong bilaterally. No epitroclear lymph nodes palpated. Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers or edema. Legs are warm bilaterally. Femoral, popliteal, dorsalis pedis, and posterior tibial pulses strongly palpated bilaterally. No apparent varicosities or superficial thrombophlebitis noted. MUSCULOSKELETAL Gait smooth, with equal stride and good base of s upport. Full ROM of TMJ with no pain, tenderness, clicking or crepitus. Sternoclavicular joint midline with swelling or redness. Normal curves of cervical, thoracic, and lumbar spine. Paravertebrals nontender. Full smooth ROM of cervical and lumbar spine. Upper and lower extremities symmetric without lesions,nodules, deformities,or swelling. Full smooth ROM against gravity and resistance.
NEUROLOGICAL Cranial Nerves: 1. Identifies correct scents 2. Vision 20/20 OS, 20/20 OD, full visual fields intact. 3,4,6 No ptosis, full extraocular movements (EOM) pupils equally round, react to light and accommodation (PERRLA) 5. Temporal and masseter muscles contract Bilaterally. Able to identify light, sharp, dull touch to forehead, cheek, and chin. Corneal reflex present. 7. Able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes against resistance. 8. Wispered 2 syllable words heard bilaterally. 9 and 10. Uvula and soft palate rise symmetrically on phonation. Gag reflex present. Swallows without difficulty. 11. Equal shoulder shrug against resistance; turns head in both directions against resistance. 12. Protrudes tongue in midline with no tremors, able to push tongue blade to right and left with no difficulty. Motor and Cerebellar System No atrophy, tremors, weakness, full ROM of all extremities. No fasciculations, tics, or tremors. Gait and tandem walk normal and steady. Negative Romberg test. Performs repetitive alternating movements, finger to nose at smooth, good pace. Runs each heel down each shin with no deviation. Sensory System Identifies light touch, dull and sharp sensations to trunk and extremities. Vibratory sensation, stereognosis, graphesthesia, two-point descrimination intact. Reflexes Reflexes 2+ bilaterally, except Achilles 1+. No Babinski present.
Checklist HEAD, FACE y y y y y y y
Inspect & palpate head for shape , symmet r y , lumps. N ote hai r col or, textur e , dist ri buti on. P alpate tempor al ar ter y. P alpate & per cuss frontal & maxillar y sinuses. Check nasal patency and wit h pen lig ht. Ask about smell (C N 1) . P alpate masseter s - clenched teet h -(C N 5, 7) T est lig ht f acial sensati on (C N 7) .
EYES y
y
y y y
ctur es. Inspect eyelids and exter nal st ru o size , shape and symmet r y of eyebrows , eyelids , eyelashes. Inspect conjunctiva , scler a for col or var iati ons , P ERRLA . o P upillar y r eacti on t o lig ht. Check 6 car dinal f ields (C N 3, 4, 6) . V isual f ields & ext r aocular muscle f uncti on. Check visi on (C N 2)
EAR y y y
Inspect & palpate ear ( note size , shape , skin conditi on , tender ness ) Inspect for ear d r ainage. H ear ing voice test (C N 8) .
J AW, MOU T H y y y y
P alpate temporomandibular j oint ,
inspect teet h, gums , t ongue , palate , and uvula.
Check t onsil fossa S ay ³ ah´ (C N 9, 10), swall ow r e f lex intact. P t. P rot ru des t ongue (C N 12) .
N ECK
y y y y y y y y y
chea midline. Inspect & palpate neck. N ote t ra Check neck ROM . P alpate t h yroid lig htly. P alpate carotids ( separ ately ) . Auscultate for br uits. Assess apical carotid pulse. P alpate cer vical lymph nodes ( identi f y all chains ) . Shr ug shoulder s (S tates C N 11) . Assess skin tur g or . P inch up skin on upper chest ar ea.
U PP ER EX T REM I T I ES y y y y y y y
Inspect ar ms skin col or, hai r dist ri buti on , Assess nails textur e , cont our & col or, capillar y r e f ill. Assess ROM and st r engt h (hand g ri ps ) . P alpate & assess r adial pulses (r ate , rh yt hm , & amplitude ) . Assess r adial apical pulse. Assess capillar y r e f ill nails. Assess deep tend on r e f lexes ( biceps , t ri ceps ) .
CHES T (Lungs ) y y y y y y y
y y
Inspect post. , lat. & ant. chest. Obser ve r ate and rh yt hm of r espi r ati ons. Check expansi on at T 9- T 10 . Assess tactile fr emitis. P er cuss side t o side (r esonance ) . Auscultate anter i or ± apex t o base , side t o side for adventiti ous sounds. Auscultate poster i or ± apex t o base , side t o side for adventiti ous sounds. o N ote Adventiti ous sound. N ote spinal cur vatur es. P alpate axillar y lymph nodes. Ask about br east sel f-exam (f emales ) .
HEART y y y y
Inspect for pulsati ons & palpate at P M I. Auscultate at Aor tic , P ulmonic , T ri cuspid , M it r al (A+ T o M e ) . Auscultate apical -r adial , & apical -carotid ( amplitude , rh yt hm , r ate ) . Identi f y S1, S2 . Listen for mur mur s , clicks. Listen for S3, S4 gallups.
ABDOME N y y y y y y y y
Inspect col or, cont our, pulsati ons. N ote scar s Auscultate bowel sounds over 4 quad r ants Auscultate aor tic sounds. Check for ascites. Lig htly palpate 1cm. over 4 quad r ants. P er cuss 4 quad r ants ( tympany ) . Check for her nias ( umbilical ) . Assess superf icial r e f lex.
LOWER EX T REM I T I ES y y y y y
Assess skin of legs , hai r dist ri buti on. Assess ROM and st r engt h . Assess deep tend on r e f lexes ( patellar, achilles ) . , and d or salis pedis pulses. P alpate & assess poster i or tibial Assess Homan¶s sign.
y y y y y
Check for edema. Assess babinski r e f lex. Assess ankle ROM and st r engt h . Inspect t oes & capillar y r e f ill. Check skin sensati on ( evaluate based on der mat ome levels ) .
