UNIVERSITY OF CEBU – BANILAD

College of Nursing

PHYSICAL ASSESSMENT FINDINGS

ADULT PHYSICAL ASSESSMENT FINDINGS

Patient’s Name: K.C.S. Age: 19 Sex: Female Civil Status: Single

Date of Birth: June 3, 2001 Place of Birth: Ormoc City, Leyte

A. SKIN, HAIR & NAILS

SKIN N A Remarks
 The client has no odor of perspiration and
1. Odor
wound odor.
The client has an evenly dark intermediate
2. Color 
skin tone without unusual discoloration.
The client has a healed scar on her left knee
3. Lesions 
and has no signs of other lesions.
The client’s skin is smooth and even; skin is
4. Texture 
neither oily or dry
5. Temperature  The client’s skin is warm and even
The client has a normally thin skin but thick
6. Thickness  on the palms of her hands and soles of the
feet.
The client’s skin can be pinched with no pain
7. Mobility 
and difficulty
Skin is elastic. The client’s skin quickly
8. Turgor 
returns to place when released.
The client’s skin rebounds and does not
9. Edema 
remain indented when pressure is released.
SCALP & HAIR
The client has a natural black hair. There
1. Color 
are no discolorations/ variations in color.
The client has varying amount of terminal
2. Amount 
and velus hair.
The client has an alopecia or patchy hair loss
3. Distribution 
on the periphery of her scalp.
The client has thick terminal hair but thin
4. Thickness 
velus hair.
The client scalp is not dry and scaly; hair is
5. Texture 
smooth and shiny
The client’s scalp is clean and dry and has no
6. Lesions 
signs of lesions.
The client’s hair has no signs of parasitic
7. Parasites 
infestations.
NAILS
Grooming & Cleanliness
The client’s nails are pink in color with
1. Color 
translucent white tips.
The client’s nails are slightly convex and the
2. Shape  angle between her nail and nail bed is about
160◦.
The client’s nails are smooth and shiny; there
3. Texture 
are no pits and grooves.
The client’s nails are firm and not brittle or
4. Consistency 
splitting and are firmly adhered to the nail
 beds.
The client’s nails return to the normal pink
5. Capillary Refill 
tone quickly after pressure is released.

B. HEAD & FACE

A. INSPECTION
The client’s head is round and is appropriate
a. Size & Shape 
in size wherein it is smaller than her chest.
b. Configuration  The client’s head is erect and in midline.
c. Consistency  The client’s head has no signs of any lesions.
The client’s head is symmetric wherein the
d. Symmetry 
left side is the same with the right side.
The client’s facial structure is symmetric
and has no swelling; there are no signs of
e. Facial Features 
drooping and involuntary muscle
movements
The client can perform different facial
expressions without any problem such as
f. Expressions 
frowning, wrinkling her nose and raising her
eyebrows.
g. Skin Condition  The client has a clear and moist skin.
The client has alopecia on the periphery of
h. Hair Distribution 
her scalp.
i. Color of Hair  The client has a natural black hair.
B. PALPATATION
The client’s head is hard and smooth and
a. Head 
without any lesions.
The client’s temporal pulse rhythm is the
b. Temporal Pulses 
same with the other pulse of the body.
The masseter muscles contract when
c. Masseter muscles 
stimulated and relax when not.
C. JOINT MOBILITY
The client can open and close her mouth
a. Retract / Protact Jaw  fully without any restrictions, tenderness or
crepitation.
The client’s jaws can move laterally between
b. Side 
1-2 centimeters in each direction.
D. FUNCTION CN V
The client can feel pain wherein she
a. Pain Sensation 
grimaces at a noxious stimulus.
The client does not feel any sharpness or dull
b. Sharp & Dull 
pain.
c. Light Touch  The client is sensitive to light touches.

TEMPORAL ARTERY N A Remarks

a. Elasticity  The client’s temporal pulse is regular.
The client’s temporal is not tender or
b. Tenderness 
not painful when palpated.
TEMPOROMANDIBULAR
There is no tenderness or the client does
a. Tenderness  not feel any pain in her
temporomandibular.
There is no swelling in the client’s
b. Swelling 
temporomandibular when palpated.
There is no sound or crackling when
c. Crepitation 
the client moves her mouth.
C. EYE
VISION TESTS
Distant Visual Acuity
Near Visual Acuity
Color Vision
Visual Fields (CN II)

EXTRAOCULAR MUSCLE
FUNCTIONAL TEST
Corneal Light Reflex
Cover-uncover Test
Positions Test CN 3,4,0
Corneal Sensitivity Reflex

EXTERNAL EYE
STRUCTURES
Eyelids & Eyelashes: INPECTION & PALPATATION
a. Palpebral Fissure
b. Color
c. Swelling
d. Lesions & discharge
e. Tremors (CN III)
POSITIONING OF EYEBALLS
CONJUCTIVA (BULBAR & Palpebral)
a. Clarity
b. Color
c. Texture
4. Palpebral Conjunctiva
5. Lacrimal Meatus : INPSECTON / PALPATION
a. Swelling
b. Redness
c. Drainage
6. Cornea & Lens
7. Iris & Pupil
a. Pupil Size
b. Shape
c. Color
8. Pupillary Light Reflex
9. Consensual Light Reflex
9. Accommodation

INTERNAL STRUCTURE
1. Red Reflex
2. Optic Disc
3. Retinal Vessels
4. Retinal Background
a. Colors
b. Lesions
5. Anterior Chamber
EA

D. EARS N A Remarks
EXTERNAL EAR STRUCTURE
INSPECTION
Auricle, Tragus, Lobule
a. Size & Shape
b. Position
c. Lesions / Discoloration
d. Discharge
PALPATATION
Auricle / Tragus / Mastoid
a. Tenderness
b. Masses
OTOSCOPIC EXAMINATION
External Auditory Canal
a. Discharge
b. Color / Consistency of cerumen
c. Color / Consistency of canal wall
d. Nodules
TYMPANIC MEMBRANE
a. Color
b. Shape
c. Consistency
d. Landmarks
e. Valsalva Maneuver
COMMENTS:
HEARING & EQUILIBRIUM
Voice – Whisper Test
Weber Test
Romberg Test
E. NOSE & SINUSES
NOSE
EXTERNAL NOSE: INSPECTION / PALPATATION
a. Color
b. Shape
c. Symmetry
d. Tenderness
e. Patency
INTERNAL NOSE : INSPECTION
a. Color
b. Swelling
c. Exudate
d. Bleeding
e. Ulcers
f. Perforated Septum
g. Polyps
3. Test CN I

SINUSES: INSPECTION / PALPATATION

a. Transillumination
b. Fronted Sinus
c. Maxillary Sinus
PALPATATION
a. Tenderness
PERCUSSION
a. Tone of Sinuses
 F. MOUTH AND THROAT
MOUTH : INSPECTION N A Remarks
ODOR
LIPS, BUCCAL, MUCOSA, GUMS
a. Color
b. Moisture
c. Consistency
d. Lesions
TEETH
a. Number
b. Color
c. Shape
d. Occlusion
HARD / SOFT PALATE
a. Color
b. Integrity
Uvula
Gag Reflex (CN X)
TONSILS
a. Color
b. Lesions
c. Grade / Size
d. Exudate

a. Color
b. Texture
c. Consistency
d. Moisture
e. Size
FRENULUM (Ventral Surface)
a. Color
b. Lesions
c. Wharton’s Duets
CN XII (Tongue Strength)
PALPATATION
a. Lips
a. 1 Lesions
a. 2 Consistency
b. Tongue
b. 1 Lesions
c. Buccal Mucosa
Test CN VII & IX
a. Sweet
b. Salty
c. Sour
d. Bitter

G. NECK
NECK : INSPECTION
LIPS, BUCCAL, MUCOSA, GUMS
a. Position
b. Symmetry
c. Lumps / Masses
d. Swelling
e. Musculature
TRACHEA / JUGULAR VIEN
ROM OF NECK
a. Position
b. Extension
c. Hypertension
d. Rotation
e. Lateral Flexion
NECK : PALPATATION N A Remarks
Lymph Nodes
A. Pre-auricular
B. Post auricular
C. Occipital
D. Submental
E. Submandibular
F. Tonsillar
G. Anterior cervical
H. Posterior cervical
I. Supraclavicular
J. Infraclavicular

TRACHEA
THYROID GLANDS : Anterior Approach
a. size
b. Irregularity
c. Masses
f. Tenderness
THYROIS GLAND : Posterior Approach
a. size
b. Irregularity
c. Masses
Carotid Arteries
AUSCULTATION
a. Thyroid
B. Carotid Arteries

H. ARMS, HANDS & FINGERS

a. Upper Extremities
a.1 Coloration
a.2 Texture
a.3 Moisture
a.4 Masses
a.5 Lesions
a.6 Muscle Size
b. Nailbed
b.1 Color
b.2 Shape
b.3 Configuration
C. Test for CN XI
c. 1 Shoulder Shrug
c.2 Slap test

PALPATION
a. Upper Extremities
a.1 Tenderness
a.2 Swelling
a.3 Temperature
a.4 Epictrochlear Nodes
a.5 Brachial Pulse
a.6 Ulnar Pulse
a.7 Radial Pulse
a.8 Muscle Tone
b. Joints, Fingers, wrist etc.
b.1 Size
b.2 Shape
b.3 Swelling
b.4 Nodules
b.5 Masses
ROM
A. Elbow N A Remarks
a.1 Extension
a.2 Flexion
a.3 Pronation
a.4 Supination
B. Shoulders
b.1 Internal Rotation
b.2 External Rotation
b.3 Flexion
b.4 Extension
b.5 Hypertension
b.6 Abduction
b.7 Circumduction
C. Wrist
c. 1 Flexion
c.2 Extension
c.3 Outward deviation
c.4 Inward deviation
d. Hands & Fingers
d.1 Abduction
d.2 Abbduction
d.3 Flexion
d.4 Hypertension
TEST MUSCLE STRENGTH
a. Deltoid
b. Biceps
c. Triceps
d. Wrist
e. Fingers
f. Grip Strength
REFLEXES
a. Biceps
b. Triceps
c. Brachioradialis

SENSORY FUNCTION
a. Light Touch
b. Pain Sensation
c. Temperature
d. Vibration
FINE TOUCH DISCRIMINATION
a. Stereognosis
b. Graphesstesia
c. Two-point discrimination
c.1 Fingers
c.2 Forearm
c.3 Dorsal Hands

MOTOR FUNCTION
a. Finger-to-Nose
b. Finger to nose Nurse’s Finger
c. Finger-to-thumb
d. Fingers-to-fingers
e. Rapid Alternating Movement
f. Proprioception
 I. POSTERIOR & LATERAL THORAX
INSPECTION N A Remarks
a. Shape & Configuration
b. Position of Sculpture
c. Rate & Rhythm of Respiration
d. Use of Accessory Muscles
e. Client Posture

SPINOUS PROCESS : PALPATATION

a. Tenderness
b. Sensation
c. Lesions
d. Masses
POSTERIOR / LATERAL THORAXES: PALPATION
a. Tenderness
b. Sensation
c. Lesions
d. Masses
e. Tactic Fremitus
CHEST EXPANSION
PERCUSSION
a. Tone
b. Intercostal Spaces
c. Lateral Aspect of the Lung
d. Diaphragmatic Excursion
e. Costo-vertebral Angle
AUSCULTATION
Breath Sounds
a. Bronchial
b. Vesicular
c. Bronchovesicular
Voice Sounds
a. Bronchopony
b. Egophony
c. Whispered Pectoriloquy
d. Adventitious Sounds
Two – point Discrimination

J. ANTERIOR THORAX
ANTERIOR CHEST : INSPECTION
a. Shape & Configuration
b. Position of Sternum
c. Costal Angle
d. Superficial Veins
e. Sputum
f. Color of chest
g. AP diameter
QUALITY AND PATTERN OF RESPIRATION : BREATHING CHARACTERISTICS RATE
a. Rhythm
b.Depth
INTERCOSTAL SPACES
a. Bulging
b. Retractions
ACCESORY MUSCLE N A Remarks
PALPATATION
a. Tenderness & Sensation
b. Lesions
c. Masses
d. Tactile Fremitus
C .Chest Expansion
AUSCULTATION
Breath Sounds
a. Bronchial
b. Vesicular
c. Bronchovesicular
Voice Sounds
a. Bronchopony
b. Egohpony
c. Whispered Pectoriloquy
Adventitious Sounds
TURGOR & MOBILITY
K. FEMALE BREASTS
INSPECTION
Inspection for the breast for size, symmetry, color, texture, superficial venous pattern, contour,
lesions or masses, size, & directions of nipples, retraction an dimpling of nipples.
a. Arms at Side
b. Arms raised overhead
c. Hands pressed on hips
d. Hands pressed togrther
e. Patient learning forward
f. Axillae
a.1 Rashes
a. 2 Infection
PALPATATION
Axilliary Nodes
a. Central
b. Anterior (Pectoral)
c. Posterior (Suprascapular)
d. Lateral (brachial)
e. Infraclavicular
f. Supraclavicular

PALPATATE BREAST FOR TEXTURE, TENDERNESS ELASTICITY, TEMPERATURE

AND MASSES
a. Concentric
b. Parallel
c. Wedge
d. Bimanual
MALE BREASTS
INSPECTION
a. Swelling
b. Nodules
c. Ulcerations

TEACH BREAST SELF EXAMINATION

a. Visual Aid
b. Mastery of Topic
c. Correctness
L. HEART & NECK VESSEL
Carotoid Artery
a. Auscultate for bruits
b. Palpate amplitude & contour
c. Elasticity of Vessel
d. Thrills
HEART: INSPECTION / PALPATION
Inspection & Palpation will include pulsations: symmetry of movement, retractions or heaves, fine
vibrations (thrills)
APICAL IMPULSE N A Remarks
Cardiac Landmarks
a. Aortic
b. Pulmonic
c. Erb’s
d. Tricuspid
e. Mitral (Apical)

HEART: AUSCULTATION
a. Aortic
b. Pulmonic
c. Erb’s
d. Tricuspid
e. Mitral (Apical)
M. ABDOMEN
ABDOMEN : INSPECTION
a. Color
b. Vascularity
c. Pigmentation
d. Striae
e. Scars
f. Lesions
g. Rashes
h. Contour
i. Symmetry
j. Abdominal Movement
k. Respiratory Movement
l. Aortic Pulsations
Umbilicus
a. Symmetry
b. Contour
c. Color
AUSCULTATION
Bowel Sounds
a. Intensity
b. Pitch
c. Frequency
Vascular Sounds
a. Abdominal aorta
b. Renal Artery
c. Iliac Arteries
d. Femoral Arteries
PERCUSSION
Tone
a. RLQ
b. RUQ
c. LUQ
d. LLQ
Liver
a. Location
b. Size
c. Liver Span
d. Scratch Test
Spleen
a. Location
b. Size
Blunt Percussion N A Remarks
a. Liver
b. Kidneys
PALPATION
Light Palpation
a. Umibilicus
b. Abdominal Reflex
c. Abdominal Quadrants
c.1 RLU
c.2 RUQ
c.3 LLQ
c.4 LUQ
Deep Palpation
Palpation
a. Abdominal Aorta
b. Liver
b.1 Consistency
b.2 Tenderness
c. Spleen Location
c.1 Consistency
c.2 Tenderness
d. Kidneys
d.1 Kidney Punch
d.2 Tenderness
e. Urinary Bladder
f. Test for Shifting Dullness
g. Fluid Wave Test
h. Ballotment Test
TEST FOR APPENDICITS
a. Rebound Tenderness
b. Rovsing’s Signs
c. Psoas Sign
d. Obturator Sign
Murphy’s Sign

ASSESS DEEP TENDON REFLEX

a. Patellar Reflex
b. Archilles Reflex
c. Plantar Reflex
d. Babinski Reflex
MOTOR FUNCTION
a. Proprioception
SPECIAL TESTS
a. Homan’s Sign
b. Position Change
(for arterial insuffieceny)
c. Trendelenburg’s Test
d. Bulge-knee Test
e. Ballotment Test
f. McMurray’s Test
INTERCOSTAL SPACES
a. Bulging
b. Retractions
ASSESS MOBILITY
a. Tandem Walk
b. Backward Walk
c. Stepping to R & L
d. Hopping on one Leg
N. LEGS, FEET AND TOES
LOWER EXTREMETIES; INSPECTION N A Remarks
a. Skin Color
b. Texture
c. Masses
d. Varicosities
e. Distribution of hair
f. Lesions
g. Edema
h. Musculature
PALPATION
a. Skin Temperature
b. Edema (Grade)
c. Inguinal Lymph nodes
d. Musculature
e. Pulses
e.1 Popliteal
e.2 Dorsalis Pedis
e.3 Tibial Pulses
e.4 Femoral Pulses
CAPILLARY REFILL
ROM
a. Flexion
b. Extension
c. Hyperextension
d. Lateral Flexion
e. Rotation
HIP
a. Extension
b. Hypertension
c. Abduction
d. Adduction
e. Flexion
KNEE / LEG
a. Flexion
b. Extension
ANKLES
a. Plantar Flexion
b. Dorsiflexion
c. Inversion
d. Eversion
TEST MUSCLE STRENGTH
a. Abduction
b. Adduction
c. Hamstring
d. Quadriceps
e. Muscles of Ankle & Feet
ASSESS SENSORY FUNCTION
a. Temperature
b. Vibration
c. Light Touch
d. Pain Sensation
e. Two-point discrimination
K. FEMALE GENETALIA
EXTERNAL GENETALIA:
N A Remarks
INSPECTION
Mons Pubis
a. Hair Distribution
b. Infestation
Labia Majora & Perineum
a. Lesions
b. Swelling
c. Excoriation
Labia Minora, Clitoris, Meatus
a. Lesions
b. Excoriation
c. Swelling
d. Discharge
PALPATION
a. Bartholin’s Gland
b. Swelling
c. Discharge
d. Urethra
e. Drainage
INTERNAL GENETALIA
Vaginal Opening
Vaginal Musculature
Speculum Examination
a. Cervix
a.1 Color
a.2 Tenderness
a.3 Position
a.4 Surface
a.5 Mobility
a.6 Discharge
a.7 Lesions
b. Vagina
b.1 Color
b.2 Surface
b.3 Consistency
b.4 Discharge
c. Ovaries
c.1 Size
c. 2 Shape

L. MALE GENETALIA
PENIS N A Remarks
PUBIC HAIR GROWTH PATTERN
a. Excoriation
b. Erythema
c. Infestation
SKIN OF THE SHAFT
a. Rashes
b. Lesions
c. Lumps
d. Tenderness
Glans Penis
a. Size & Shape
b. Lesions
c. Location of U. meatus
d. Urethral Discharge
SCROTUM N A Remarks
INSPECTION
a. Size
b. Shape
c. Position
d. Swelling
e. Lumps
f. Bulges
g. Skin Color
h. Integrity
PALPATION
Scrotal Sac
a. Size
b. Shape
c. Consistency
d. Tenderness
e. Nodules
TRANSILLUMINATION
a. Mass
b. Swelling
INGUINAL AREA
a. Bulges
b. Masses
PALPATE THE SCROTAL AREA
TESTICULAR SELF EXAM
a. Mastery
b. Visual-aid
REFLEXES
a. Bulbocarvenosus
b. Cremasteric
a. Abdominal Aorta
b. Liver
b.1 Consistency
b.2 Tenderness
c. Spleen Location
c.1 Consistency
c.2 Tenderness
d. Kidneys
d.1 Kidney Punch
d.2 Tenderness
e. Urinary Bladder
f. Test for Shifting Dullness
g. Fluid Wave Test
h. Ballotment Test
TEST FOR APPENDICITS
a. Rebound Tenderness
b. Rovsing’s Signs
c. Psoas Sign
d. Obturator Sign
Murphy’s Sign
TRANSILLUMINATION N A Remarks
a. Mass
b. Swelling
INGUINAL AREA
a. Bulges
b. Masses
PALPATE THE SCROTAL AREA
TESTICULAR SELF EXAM
a. Mastery
b. Visual-aid
REFLEXES
a. Bulbocarvenosus
b. Cremasteric
M. ANUS, RECTUM & PROSTATE
INSPECTION
a. Lumps, Ulcer, Lesion etc.
a.1 Size
a.2 Location
a.3 Distribution
a.4 Configuration
b. Sacroccygeal Area
a. Swelling
b. Redness
c. Dimpling
d. Hair
c. Perform Valsalva Maneuver
PALPATION
a. Anal Sphineter
a.1 Tone
a.2 Tenderness
a.3 Nodules
a.4 Hardness
RECTUM / PROSTATE
PALPATION
a. Rectal Mucosa
a.1 Tenderness
a.2 Irregularities
a.3 Nodules
a.4 Hardness
b. Peritoneal Cavity
b.1 Tenderness
b.2 Nodules
b.3 Rectal Shelf
c. Prostate Gland
c.1 Tenderness
c.2 Size
c.3 Shape
c.4 Texture
c.5 Irregularities
INSPECTION (FECES)
a. Presence of Blood
 NEUROLOGICAL ASSESSMENT
CRANIAL NERVES N A Remarks
1. CN I – Ofactory
2. CN II – Optic
3. CN III – Oculomotor
4. CN IV – Trochlear
5. CN V – Trigeminal
6. CN VI – Abducens
7. CN VII – Facial
8. CN VIII – Acoustic
9. CN IX – Glossopharyngeal
10. CN X – Vagus
11. CN XI – Spinal Accessory
12. CN XII - Hypoglossal
MOTOR / CEREBELLAR
1. Condition / movement of muscles
2. Test Balance
3. Test Coordination
SENSORY SYSTEM
1. Test for pain
2. Test for temperature
3. Test vibratory sensation
4. Test position sensations
5. Test fine touch
REFLEXES
1. DEEP TENDON REFLEXES
a. Biceps
b. Brachioradialis
c. Triceps
d. Patellar
e. Achilles
f. Ankle Clonus
2. SUPERFICIAL REFLEXES
a. Plantor
b. Abduction
c. Cremasteric
TEST FOR MENIGEAL IRRITATION
a. Brudzinki’s Sign
b. Kernig’s Sign

Name of Student_____________________________ Year & Section______________

Criteria: Accuracy (20) ... ______________

Comprehensiveness (20) ... ______________
Completeness (20) ... ______________
Neatness (5) ... ______________

TOTAL (60) ... ______________