CHARTING EXAMPLES FOR

PHYSICAL ASSESSMENT
CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT
SKIN, HAIR AND NAILS
Skin pink, warm, dry and elastic.  No lesions or excoriations noted.  Old appendectomy scar right
lower abdomen 4 inches long, thin, and white.  Sprinkling of freckles noted across cheeks and nose. 
Hair brown, shoulder length, clean, shiny.  Normal distribution of hair on scalp and perineum.  Hair
has been removed form legs, axillae.  Nails form 160 degree angle at base, are hard, smooth, and
immobile.  Nailbeds pink without clubbing.  Cuticles smooth, no detachment of nailplate.  Hands
well-manicured with clear enamel.
                                                          
HEAD AND NECK
Head symmetrically round, hard, and smooth without lesions or bumps.  Face oval, smooth, and
symmetrical.  Temporal artery elastic and nontender.  Temporomandibular joint palpated with full
range of motion without tenderness.  Neck symmetric with centered head position and no bulging
masses.  C7 is visible and palpable with neck flexion.  Has smooth, controlled, full range of motion
of neck.  Thyroid gland nonvisible but palpable when swallowing.  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.  Extraocular
movements smooth 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
appear moist and smooth.  Sclera white with no lesions or redness.  No swelling or redness over
lacrimal gland.  Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities. 
Irises are round, flat, and evenly colored.  Pupils are equal in size and reactive to light and
accommodation.  Pupils converge evenly. 
Ears are equal in size bilaterally.  Auricles are aligned with the corner of each eye.  Skin smooth, no
lumps, lesions, nodules.  No discharge.  Nontender on palpation.  Small amount of moist yellow
cerumen in external canal.  Whisper test : patient repeats 2 syllable word.

MOUTH, THROAT, NOSE, AND SINUS

Lips pink, smooth, and moist without lesions.  Buccal mucosa pink, moist, and without exudates. 
Stensen/s ducts visible with no redness or swelling.  32 white to yellowish teeth present.  Gums pink
without redness or swelling.  Protrudes geographic tongue in midline with 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.  
Nose somewhat large but smooth and symmetric.  Able to sniff through each nostril. Nasal septum
slightly deviated to the left, but does not obstruct airflow.  Inferior and middle turbinates dark pink,
moist, and free of lesions.  No purulent drainage noted.  Frontal and maxillary sinuses  are nontender
to palpation and percussion.

THORAX AND LUNG

Respirations 18/minute, relaxed and even.  Anteroposterior less than transverse diameter.
Chest expansion symmetric.  No retraction or bulging of interspaces.  No pain or tenderness on
palpation.  Tactile fremitus symmetric.  Percussion tones resonant over all lung fields.  Vesicular
breath sounds auscultated over lung fields.  No adventitious sounds present.

BREASTS AND LYMPHACIC

Bilateral breasts moderate in size, pendulant, and symmetric.  Breast skin pale, pink with light brown
areola.  Nipples everted bilaterally.  Free movement of breasts with position changes of arms and
hands.  No dimpling, retraction, 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 support.  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 eye-
            brows, 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.