Physical Assessment

Date and Time of Assessment:_____________________ Date and Time of Admission:_____________________________________

Name of Agency/Institution:__________________________________
Area:__________________________________________________________
Name of Patient:______________________________________ Age:___________ Sex:___________ Civil Status:_________________
Chief Complaints:_________________________________________________________________________________________________
Medical Diagnosis:________________________________________________________________________________________________
Admitting Physician:_______________________________________________________________________________________________
VITAL SIGNS
Temperature: Pulse Rate: Respiratory Rate: Blood Pressure:
BODY PART INTERPRETATION/
NORMAL FINDINGS SIGNIFICANT FINDINGS
EXAMINED ANALYSIS
INTEGUMENTARY SYSTEM
Inspection
Color:___________________________________
❑ Uniform color with slightly darker exposed areas
❑ No lesions
❑ No central cyanosis ❑No peripheral cyanosis

Palpation
Temperature: ❑ Warm ❑ Cold
Skin Texture: ❑ Soft/fine ❑ Coarse/thick
Moisture: ❑ Dry ❑ Moist
Turgor: Body Part:____________ Seconds:___________ If skin lesions are present:
Size:
Shape
Notes:_____________________________________________________ Texture:
__________________________________________________________ Surface Relationship:
__________________________________________________________ Exudate:
Tenderness:
__________________________________________________________ Configuration:
Location and Distribution:
Inspection
Hair Color:___________________________________

Distribution
❑No evidences of Alopecia ❑ Normal balding pattern
❑ Evenly distributed covers the whole scalp
Quantity: ❑ Thick ❑Thin

Body Hair
❑ Fine body hair noted over most of the body
❑ Increased hair growth on legs, axillae, and pubic area.
Quantity: ❑Thick ❑Thin

Palpation:
Texture: ❑ Coarse ❑ Smooth
Moisture:❑ Dry ❑ Moist/Oily

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
❑ Lighter in color than the complexion
❑ Free from lice, nits and dandruff

Palpation
Texture: ❑ Dry ❑ Moist/Oily
❑ No tenderness ❑No masses ❑ No lesions
Scalp
❑No scars noted ❑ Freely movable

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Nails Inspection
Color: ❑Pink ❑ Light brown others:____________

Condition,shape, and angle

❑ Well groomed ❑Convex ❑ Cuticle pink and intact
❑ Angle of attachment 160°

Palpation
Texture: ❑Smooth and firm ❑ No ridges
Capillary Refill Test:___________second/s

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
 __________________________________________________________

HEAD
Inspection
Head Circumference:___________cm
Head Position: ❑ Erect and Midline position
Head Shape: ❑Normocephalic ❑ Symmetrical
❑ Contour Rounded

Palpation
Head Contour/Facial Structures
Head
❑Symmetrical ❑No masses ❑Non tender ❑ No lesions
❑ No unexpected contours or bulges

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

FACE
Inspection
Facial Appearance
❑Appropriate facial expression
❑ Symmetrical features and movement
❑ Hair distribution appropriate for age, sex, and ethnicity
❑No Lesions ❑ No Abnormal movements
❑Nasolabial folds symmetrical ❑ Palpebral fissures symmetrical
Face
Palpation
Facial bones: ❑Smooth ❑Intact ❑ Symmetrical ❑ Nontender
❑Good muscle tone ❑No crepitation ❑ Full active ROM

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
Palpation
❑ Smooth ❑ Symmetrical motion
❑ No pain ❑ No crepitus/Clicking
Temporo-
Mandibular Notes:_____________________________________________________
Joints __________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
External Nose
❑Midline Position ❑Symmetrical ❑ No Drainage
❑No Deviation ❑No Flaring ❑ Intact Septum

Internal Nasal Mucosa

❑ Pink ❑ Moist ❑ No Lesions ❑ No Edema
❑ No Discharges ❑Septum located midline
Nose
Palpation
❑Non Tender ❑No Deformities ❑ Patent Nares
❑ Slightly mobile

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
❑ Pink in color Others:_______________________
❑ Moist ❑Intact ❑ No Lesions ❑ Cheilosis
❑ Midline . ❑ No Pursed lip breathing

Palpation
Lips ❑ Soft ❑ Nontender

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Oral Mucosa and Inspection

Gums ❑ Pink ❑ Moist ❑ Intact Mucosa ❑ No Bleeding
❑ No Halitosis

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
 __________________________________________________________

Inspection
❑ Pink ❑Intact ❑ Smooth

Hard and Soft Notes:_____________________________________________________

Palate __________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
❑ Pink in color with white taste buds at the center
❑Midline position ❑ No Lesions
❑Full Mobility ❑ No Involuntary Movements
❑ Intact Mucosa

Palpation
Tongue
Texture: ❑Rough ❑ Moist

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
Number:_____________ Color:______________

Teeth

❑Smooth Edge ❑ Good Occlusion ❑ No Caries

❑No loose tooth ❑No Dental Fillings

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
Frontal
❑Clear ❑Positive Transillumination ❑ Non Tender
❑ No periorbital Edema ❑ No Discoloration

Maxillary
❑Clear ❑Positive Transillumination ❑ Non Tender
❑ No periorbital Edema ❑ No Discoloration
Sinuses
Palpation/Percussion
Maxillary: ❑ No Tenderness ❑ Resonant Tone
Frontal: ❑No Tenderness ❑ Resonant Tone

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

EYES AND EARS

Eyes Inspection
General Appearance: ❑Clear and Bright ❑ Equal Parallel Alignment

Eyelids
❑ Color consistent with clients complexion❑No Lesions ❑ No Edema

Eyelashes
❑Evenly distributed ❑No Ectropion ❑ No Entropion

Lacrimal Ducts
❑ No excessive tearing, drainage, edema ❑ No dryness

Conjunctiva
❑ Clear ❑ Pink ❑ Moist ❑ No lesions

Sclera
❑ White and intact ❑ No lesions and tears
 Cornea
❑Clear without opacities ❑ No lesions and abrasions
❑ Positive corneal reflex

Iris
❑ Round and symmetrical

Pupils
❑Size 3-5 mm ❑ No miosis ❑No mydriasis ❑ PERRLA

Palpation
Eyeball: ❑ Firm and tender
Lacrimal Gland: ❑ Non Tender

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
External Ear
❑ Vertical position with < 10 degree lateral posterior slant
❑Aligned with eyes ❑Symmetrical ❑ No redness
❑No lesions ❑No drainage ❑ No foreign objects
❑ Small amount of yellow cerumen and hair

Tympanic Membrane
❑ Pearly gray ❑ Intact ❑ No lesions or exudates
❑ No bulging or retraction
Ears
Palpation
External Ear
❑Helix is soft and pliable ❑Non tender ❑ No nodules or lesions

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

NECK
Inspection
❑Midline position ❑Erect
❑Full ROM ❑No masses

Neck Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Palpation
❑Nonpalpable ❑ Nontender
❑Palpable (Small, smooth edge of thyroid may be palpable)

Auscultation
❑No bruits
Thyroid Gland
Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Palpation
❑Midline
❑ No deviation Bronchial breath sounds heard over trachea

Trachea Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Neck Vessels: Inspection

Carotid Arteries ❑Visible carotid pulsation ❑ Jugular venous pressure at 45°<3 cm
and Jugular ❑No neck vein distention ❑ Jugular pulsation undulated
Veins
Palpation
Carotid:
❑ Regular rhythm ❑ Equal contour
❑Smooth upstroke with less acute descent

Jugular:
❑ Easily obliterated and fills appropriately
 Auscultation
Carotid: ❑ Negative carotid bruits
Jugular Veins: ❑ Negative venous hum

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

THORAX
Inspecton
❑Quite respiration ❑Symmetrical ❑ Regular rhythm and depth
❑ Anteroposterior lateral ratio 1:2 ❑No barrel chest
❑No spinal deformities ❑Skin Intact
❑No retraction or use of accessory muscles

Palpation
❑Non tender ❑ No masses ❑ No crepitus
❑Symmetrical excursion anteriorly and posteriorly
❑Tactile fremitus equal bilaterally

Percussion
❑Anterior: Resonance ❑Lateral: Resonance
❑Posterior: Resonance ❑ Diaphragmatic: Resonance
Chest
Auscultation
Breath Sounds
❑All lung fields clear ❑Bronchial breath sounds heard over trachea
❑Bronchovesicular breath sounds heard over sternum anteriorly and
between scapula posteriorly
❑Vesicular sounds heard in most lung fields
❑No abnormal or adventitious breath sounds
❑No abnormal voice sounds ❑No bronchophony
❑No whispered pectoriloquey ❑No egophony

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
❑Lobular ❑ Symmetrical ❑ Slightly symmetrical
❑Color Consistent with body color ❑ No masses ❑ No lesions
❑No edema ❑ No dimpling ❑No retractions ❑ No orange peel skin

Palpation
❑Premenopausal: more firm and elastic
❑During pregnancy and lactation: firm and tender
Breast ❑Postmenopausal: less firm and elastic with stringy ducts
❑Nontender ❑Tender and Nodular
❑No masses ❑No lesions

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
Areola
Color:_____________________________
❑Symmetrical ❑ Round
❑No masses ❑ No lesions❑ No discharges
❑Spontaneous discharge (during pregnancy & lactation)

Nipples
❑Everted Flat ❑ No supernumerary nipples ❑ Inverted
Nipple and Areola
Palpation
❑Elastic ❑ Non-tender ❑No discharges
❑White sebaceous secretion upon nipple compression

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Axilla Inspection
❑Skin intact ❑ No lesions or rashes
❑Hair growth appropriate to clients age & sex

Palpation
❑Non-palpable & Non-tender lymph nodes
 Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

HEART
Palpation
PMI at apex:____________cm
❑Non-sustained ❑ Non-palpable ❑No diffusion

Percussion
__________________________________________________________
__________________________________________________________
__________________________________________________________

Auscultation
Precordium
Hives Bruit/Murmurs Gallops
__________________________________________________________
__________________________________________________________
__________________________________________________________

Notes:_____________________________________________________
__________________________________________________________
Pulse bpm Grade
__________________________________________________________
Temporal
__________________________________________________________
Carotid
Pulses:
Brachial
Grade Amplitude Radial
0 = absent
1= weak Apical
2 = normal Femoral
3 = full
4 = bounding Popliteal

Dorsalis pedis

Posterior Tibialis
Pulse

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

ABDOMEN
Abdomen Inspection
Abdominal Girth
❑ Skin color consistent
❑ No lesions
❑No superficial veins
❑No rashes
❑Flat
❑Symmetrical
❑No hernia
❑No peristaltic waves
❑Hair distribution appropriate for clients age and gender
❑ Slightly lighter than exposed areas
❑ No striae
❑ No scars
❑No discoloration
❑Slightly rounded
❑ No bulges
❑Positive respiratory movements
❑Slight pulsation in epigastric region

Umbilicus
❑Midline ❑Inverted ❑No discoloration ❑No discharge

Auscultation
❑Soft, medium-pitched bowel sounds every 5-15 seconds in all four
quadrants
❑No borborygmi ❑No bruits ❑No hums ❑No rubs

Percussion
❑Tympany in all four quadrants
❑Dullness over organs

Palpation
Skin Turgor:_______________________
❑Tympany in all four quadrants
 ❑Dullness over organs ❑Organs Nontender
❑Soft ❑Nontender
❑Positive skin turgor ❑Negative umbilical bulges
❑Positive abdominal reflexes ❑ No masses

Liver: ❑Nonpalpable ❑Nontender

Spleen: ❑Nonpalpable ❑Nontender
Kidneys: ❑Nonpalpable ❑Nontender
Inguinal Lymph Nodes: ❑Nonpalpable ❑Nontender

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

GENITOURINARY SYSTEM
Inspection

External:
❑ Pink Color (depends on clients pigmentation) others:____________
❑ Intact ❑ Moist❑ No lesions ❑ No edema
❑No discharge ❑ No odor ❑ No prolapse

Female Rectal Area

Genitourinary ❑ Intact ❑No inflammation ❑No lesions ❑ No prolapse
❑No hemorrhoids ❑No discharge ❑ No bleeding

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
Color:_____________________________________
❑Skin intact ❑No lesions ❑ No discharges
❑No lesions ❑No pediculosis ❑Foreskin retracts easily
❑Urinary meatus midline at tip of glans

Scrotum
❑Skin color darker than rest of body
❑Appropnate size for age of client
❑Testes hang freely ❑Left testis slightly lower than right

lnguinal Area
❑Skin intact❑No bulges❑No palpable lymph nodes

Rectal Area
❑Rectal area intact ❑No inflammation ❑No lesions
❑No prolapse❑No hemorrhoids ❑No discharge
❑No bleeding

Palpation
Male For nonerect penis: ❑Soft ❑ Nontender ❑ No nodules
Genitourinary
Scrotum, testes, and epididymis:
❑Scrotal skin rough ❑ No swelling of epididymis
❑ No lesions ❑Testes rubbery, round, movable and smooth

lnguinal Area
❑No hernias ❑ No masses ❑ No palpable lymph nodes

Anus and Rectum

❑Nontender ❑ No masses ❑ No polyps
❑ No lesions ❑ No bleeding ❑ No hemorrhoids
❑ Positive sphincter tone

Ausculation
❑ No bowel sounds

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

MUSCULOSKELETAL SYSTEM
Posture & Inspection
Spinal curves ❑ Erect posture ❑ Head midline
❑Normal spinal curves ❑ Knee aligned

Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
 Inspection
❑ Gait smooth, fluid, and rhythmic ❑ Arms swings in opposition
❑ No toeing in or out

Gait Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

Palpation
❑ Soft and pliable (at rest)
❑ Positive muscle tone, firm, no involuntary movements or tenderness

Muscle Tone Notes:_____________________________________________________

__________________________________________________________
__________________________________________________________
__________________________________________________________

Inspection
❑ Hand grip strong and equal
❑ Foot push and leg raise against resistance strong and equal

Grade: Grade:

Grade: Grade:

Muscle Strength
Notes:_____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________

SENSORY-NEUROLOGICAL SYSTEM
Craniel Nerves CN I — Olfactory:

❑ Sense of smell intact

Assessment:________________________________________________
__________________________________________________________

CN II — Optic:

❑ Extraocular muscles intact OU

❑ PERRLA direct and consensual
Assessment:________________________________________________
__________________________________________________________

CN III- Oculomotor, IV- Trochlear, VI — Abducens:

❑ Sense of smell intact

Assessment:________________________________________________
__________________________________________________________

CN V — Trigeminal:

5
Jaw muscle strength score: +_____
❑ Facial sensation intact ❑ Positive corneal reflex
Assessment:________________________________________________
__________________________________________________________

CN VII — Facial:

❑Facial movements symmetrical ❑ Taste on anterior tongue intact

Assessment:________________________________________________
__________________________________________________________

CN VIII — Acoustic:

❑Hearing intact❑Balance intact

Assessment:________________________________________________
__________________________________________________________

CN IX — Glossopharyngeal and X — Vagus:

❑Strong and clear voice ❑ Symmetrical rise of uvula

❑Able to swallow and cough ❑ Positive gag reflex
❑Taste on posterior tongue intact
Assessment:________________________________________________
 __________________________________________________________

CN XI - Spinal:

Muscle strength of neck and shoulders: +_____

Assessment:________________________________________________
__________________________________________________________

CN XII - Hypoglossal:

❑Full ROM of tongue❑Midline tongue

❑No atrophy
Assessment:________________________________________________
__________________________________________________________

Behavior
❑Well-groomed ❑Erect Posture
❑Pleasant facial expression ❑Appropriate affect
Level of consciousness
❑Awake ❑ Alert ❑Oriented
Glasgow Coma Scale
Score:____________

1 2 3 4 5 6
Does not Opens eyes in
Opens eyes in Opens eyes
Eye open N/A N/A
response to response to voice spontaneously
eyes
painful stimuli
Incomprehensi Utters Oriented.
Makes no Confused.
Verbal ble inappropriate converses N/A
sounds disoriented
sounds words normally
Extension to Abnormal flexion
Flexion/ Localizes
Makes no Painful to painful stimuli Obeys
Motor Withdrawal to painful
movements stimuli(decereb (decorticate commands
painful stimuli stimuli
rate response) responses)

Memory
❑Immediate memory intact ❑Recent memory intact
❑Remote memory intact
Mathematical/Calculative ability
❑Calculative skill intact
General knowledge
❑Vocabulary appropriate ❑ General knowledge intact
Thought process
❑Clear ❑Responds appropriately
❑Speech coherent and logical
Abstract thinking
❑Abstract thinking intact
Judgement
❑Judgement intact
Communication
❑Clear speech ❑Fluent ❑No dysarthria
❑No dysphasia ❑ No dysphonia ❑No neologism
❑No circumlocution ❑Intact communication skills
Light touch, pain, and temperature
❑Intact
Discriminatory Sensation:
Sensory Stereognosis: ❑ Intact
Function Grapesthesia: ❑ Intact
Two-point discrimination: ❑ Intact
Point localization: ❑ Intact
Extinction: ❑ Intact
(Grade DTR's on 0-4 scale)
Biceps: Score:_________
Deep Tendon Triceps: Score:_________
Reflexes Brachioradialis: Score:_________
Patellar: Score:_________
Achilles: Score:_________