Introduction:

Hand washing and privacy

“You can go ahead and take a seat”
“My name is Danielle Pelini and I’ll be your student nurse today.”
“Can you start off by telling me your name?”
“Okay, why are you here today?”
“Can you tell me where you are?”
“Can you tell me what year it is?”
“Can you tell me who our president is?”
“Good, now on a scale from 0 to 10, 0 being no pain and 10 being the worst possible
pain, can you rate the pain you are feeling.?”
“Okay great! So as I walked in I noticed your gait was steady and smooth. Your alert
and oriented. Your speech is clear and articulate. You appear your stated age and
are dressed appropriately.”
“Now I’m going to start your head-to-toe assessment!”

Head/Face:
“First I am going to start by examining your head. Let me know if you feel any pain
or tenderness.”
Palpate head; Inspect hair/scalp.
“Your hair appears clean and evenly distributed. Your head is free of lesions, masses,
and parasites. “
Papate face
“Your facial structures appear symmetrical and proportionate. There are no lesions
or edema.”

Ears:
“I’m now going to palpate your ears. Let me know if your feel any pain or
tenderness.”
Palpate pinna, tragus, lobules bilaterally
“The ears are equal bilaterally. There is no swelling or lesions.”
Use pen light to look into ears
“No discharge or cysts.

Eyes:
“Now I’m going to examine your eyes.”
“The eyes and eyebrows seem symmetrical. Hair evenly distributed. There appears
to be no swelling around the eyes or lid lag. Eyelid covers top of iris.”
“Can you close your eyes for me? No open.”
“Eyes open and close together.”
Pulls lids down
“Sclera is white, conjunctiva is clear and underlying mucosa is pink. There is no
crusting or discharge. Iris is blue in color. “
Use penlight  and 
“Pupils are a size 4, constrict to size 3. Constrict together.”
“Focus on my finger. Now the wall, and back to my finger. “
“Pupils accommodate.” (PERRLA= 5+)

Nose:
“Now I’m going to palpate your nose, let me know if you feel any pain or
tenderness.”
Palpate nose
“Nose is symmetrical with no lesions”
“Can you lean your head back now?”
Look in nose with pen light
“Septum is not deviates, nasal passages are patent, mucosa is ink and there is no
drainage.”
“Now put one finger on one nostril at a time and breathe in.”
“Good, air ways are most and clear.”

Mouth:
“Your lips look moist, symmetrical, with no lesions are cracks.”
“Now can you smile for me?”
“Teeth look white, straight and appear well maintained.”
Pull lips down and up; Look in cheeks and under tongue with penlight
“Buccal mucosa and gums are pink with no lesions.”
“Can you open your mouth for me and stick your tongue out.”
Look in with stick: Tongue, sides, and tonsils.
“Tonsils 2+ and equal bilaterally.”
“If you can, lift your tongue up to the roof of your mouth.”
“Okay now stick your tongue out and say Ahh.”
“Uvula rise upon phonation.”

Lymphnodes:
“Now I’m going to palpate your lymph nodes, let me know if you feel any pain or
tenderness.”
Palpate and name
-Preauricular, postauricular, occipital, submandibular, submental. Jugulodigastric,
deep cervical chain, superior cervical, posterior cervical, supraclavicular.

Skin:
Inspect
“Skin appears pinkish/tan with no lesions.”
palpate bilaterally for temp and edema
“Skin is warm and dry, no edema or swelling at the ankles.”
Test turgor (back of hand, clavicle)
“Turgor is normal, well-hydrated”
Check nails/Capillary refill (both hands/big toes)
“Nails are clean and well manicured, there is no clubbing and capillary refill is under
3 seconds.”
Neck:
“Now I’m going ot check your carotid pulse”
Palpate one at a time
“2+ bilateral carotid pulse”
Use stethoscope (bell) go check for bruits on each side.
“Hold your breath for me”

Respiratory:
From behind palpate back.
“Warm, no lesions.”
Perform chest expansion test
“If you’ll take a big breath in for me; breathe out. Symmetric.”
Use stethoscope to auscultae
“Every time you feel my stethoscope take a breath in and out.
From front palpate chest
“Skin is warm, dry, with no lesions, abnormalities, cysts, or moles. Umbilical is
midline.”
Chest expansion test
“1:2 AP diameter.”
“Now I’ll check your breath sounds.”
Use stethoscope to check lungs.
“Clear and even breathe sounds.”

Cardiac:
“I’ll have you lay back for me”
45 degrees, pull legs out
“Now I’m going to check for jugular vein distension, if you could tilt your head to the
left.”
Shine light
“No apparent pulsations or JVD.”
“Now I’m going to check your heart, so I’m going to lay you completely down.”
“I am going to check your apical pulse at FICS, LMCL.”
Palpate, find pulse
“Now I’m going to listen your heart sounds”
Diaphragm then bell
AORTIC- 2 ICS, R Sternal Border
PULMONIC- 2 ICS, L Sternal Border
TRICUSPIC- 4 ICS, L Sternal Border
MITRAL- 5 ICS, MCL

Abdomen:
“Now I’m going to go ahead and check your abdomen.”
Use light and look from side/foot of book.
“Countour flat, abdomen symmetric.”
“Now I’m going to listen to your bowel sounds” RLQ, RUQ, LUQ, LLQ
“Your bowel sounds are normal”
“Now I’m going to percuss each quadrants” RLQ, RUQ, LUQ, LLQ
“Tympani if all four quadrants”
“Now I’m going to palpate, let me know if you feel any pain or tenderness.
Palpate lightly (all around naval)

Peripheral Vascular:
“I’ll be checking your pulses now.”
Temporal, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial.
“2+ and equal bilaterally” (after each)

Neuromuscular:
“I’m going to have you sit back up for me.”
-Head: Back and forth, up and down, front and back (W/ resistance)
-Shrug shoulders
-Touch hands to shoulders, extend.
-Pronate/supinate (faster)
-Squeeze fingers
-Arms up and down (w/ resistance and gravity)
-Fingers up and down, spread fingers.
-Touch your thumb to each finger
-Legs up and down (w/ resistance and gravity)
-feet up and down, in and out (w/ resistance)
-toes up and down, spread toes.
“I’m going to check your patellar reflect now.”
Use hammer to check reflex
“Good, 2+”
“You can stand now”
“Can you put your leg out to the side? Now across your body. Okay other leg.”
“Muscle resistance=5+, ROM= 5+

Spine:
“I’ll go ahead and have you touch your toes as I check for scoliosis.”
“Slight curvature.”
“Bend both ways for me; now backwards” Hold hips
“No curvature, excercises performed with ease.”
“Walk a line, toe-to-toe.”
“Gait steady and smooth.”
“Now close your eyes. Let me know if you start to feel dizzy.”
“Okay you can open them. No swaying. Negative Romberg.”
“Will you put your hands out to your sides. Now touch your nose with your pointer
finger alternating hands.”
“Now with your eyes closed.”

“Great. This concludes your physical exam, do you have any questions for me?”