PHYSICAL ASSESSMENT GUIDE

For group 1 only

Family Name First Name Middle Initial Sex & Age

( ) Male ( ) Female

Chief complaint/signs and symptoms present

Chief complaint:

( ) Altered mental sensorium ( ) Diarrhea ( ) Jaundice

( ) Anorexia ( ) Difficulty swallowing ( ) Nosebleed
( ) Body weakness ( ) Dizziness ( ) Shortness of breath
( ) Blurring vision ( ) Dry Cough ( ) Palpations
( ) Constipation ( ) Edema, where?________________ ( ) Skin rash
( ) Cough w/ blood ( ) Fever ( ) Stool, bloody or black/tarry
( ) Cough w/ phlegm ( ) Headache ( ) Vomiting
Others (i.e. OPQRST for pain assessment, symptoms not available above)

Diagnosis

Operation Performed

Date and Time of Physical Examination Vital signs BP: PR: RR: Temp:

General Survey: ( ) Awake and alert ( ) Altered sensorium

Weight: Height: Age: BMI:
Do you have problems with eating or your appetite? ( ) No ( ) Yes
Do you have trouble sleeping? ( ) No ( ) Yes
Experiencing fever, chills, or night sweats lately? ( ) No ( ) Yes
SKIN
( ) Uniform in color, color ( ) Not uniform in color
( ) Rash ( ) Itching ( ) Presence of edema ( ) Presence of abrasions ( ) Lesions ( ) Lumps ( ) Swelling
Location (i.e. edema – right arm):
Tattoos? ( ) No ( ) Yes, location Piercings? ( ) No ( ) Yes Scars? ( ) No ( ) Yes, location
Enlarged moles? ( ) No ( ) Yes, location Foul body odor? ( ) No ( ) Yes Skin turgor:
Other findings:

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NAILS
( ) Clubbed finger ( ) Splitting noted Capillary refill time:
Other finding:

HAIR
Color of hair: ( ) Curly ( ) Straight ( ) Evenly Distributed ( ) Not evenly distributed
Dandruff ( ) No ( ) Yes Odor present ( ) No ( ) Yes Presence of parasitic insects ( ) No ( ) Yes Masses ( ) No ( ) Yes
Other findings:

HEAD
Shape: Symmetric? ( ) No ( ) Yes if no, describe:
Presence of ( ) Bruises ( ) Lesions ( ) Swelling ( ) Abnormal twitching ( ) Bulges ( ) Depression
Nerve V-Trigeminal (touch patient’s face lightly and ask if they can feel it): ( ) Intact ( ) Not intact
Nerve VII-Facial (ask patient to close their eyes, smile and look up. Are they able to do it voluntarily?) ( ) Intact ( ) Not intact
Nerve XI-Accessory (are they able to raise their shoulders against resistance?) ( ) Intact ( ) Not intact
Other findings:

EYES
Eye color: Sclera color: Pupils:
Glasses ( ) No ( ) Yes, grade of glasses: Contact lens? ( ) No ( ) Yes Any changes in vision recently?
Double vision ( ) No ( ) Yes Reactive to light ( ) No ( ) Yes Discharges present ( ) No ( ) Yes
Pain ( ) No ( ) Yes Dry eyes ( ) No ( ) Yes Itchy eyes ( ) No ( ) Yes
Visual acuity: L: R: Both eyes:
Nerve III-Oculomotor and IV-Trochlear (can they keep track of the finger movements?) ( ) Intact ( ) Not intact
Nerve II-Optic ( ) Full visual field ( ) Blind spots present
Other findings:

EARS
( ) Same size ( ) Consistent color with the face Hearing problem ( ) No ( ) Yes, describe
Hearing aid ( ) No ( ) Yes Any recent changes in hearing?
Presence of ( ) Ringing in the ears (tinnitus) ( ) Ear pain ( ) Drainage/Discharges ( ) Visible Swelling
Other findings

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NOSE
( ) Runny nose ( ) Nosebleed ( ) Sinus pain ( ) Nasal flaring ( ) Reduced sense of smell
Other findings:

MOUTH
( ) Sore throat ( ) Hoarseness/voice changes
Lips (Observation):
Buccal mucosa (Observation):
Teeth: ( ) Caries present ( ) Abscess noted ( ) Complete set of teeth
Gums: ( ) Bleeding noted ( ) Receding gums
Tongue:
Tonsils: ( ) swollen or inflamed others:
Other findings:

NECK AND LYMPH NODES

( ) Lymph nodes palpated ( ) Enlarged thyroid
Other findings:

BREAST & AXILLA

( ) Discharges noted ( ) Swelling noted ( ) Lumps palpated ( ) Pain present
Other findings:

LUNGS & THORAX

( ) Coughing, circle (dry / sputum or phlegm / blood) ( ) Wheezing ( ) Shortness of breath
( ) Trouble breathing during exercise ( ) Snoring ( ) Trouble breathing while lying down
( ) (circle) Masses / Tenderness / Lumps present ( ) Resonant sound
Other findings:

CARDIOVASCULAR
( ) Chest pain ( ) Fast pulse ( ) Slow pulse ( ) Thrills (palpable murmurs)
( ) Murmurs present, specify ( ) S3 present ( ) S4 present (atrial gallop)

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Other findings:

GASTROINTESTINAL / ABDOMEN
( ) Abdominal pain ( ) Vomiting ( ) Diarrhea ( ) Constipation ( ) Blood in stool ( ) Decreased appetite
( ) Tympanic sound present ( ) (circle) Masses / Lumps / Tenderness palpated ( ) Liver enlarged
Other findings:

NEUROLOGICAL
( ) Dizziness
( ) Weakness of muscles
( ) Trembling present
Other findings:
( ) Numbness/tingling in the arms, hands, legs, or feet (circle location) ( ) Seizures
( ) Pain when moving/walking ( ) Slurred speech ( ) Confusion ( ) Headache
( ) Difficulty concentrating

GENITAL AND URINARY

( ) Changes in frequency / volume of urine, indicate:
( ) Pain / burning when urinating ( ) Urinate often at night
Other findings:

MUSCULOSKELETAL
( ) Joint pain, specify location ( ) Joint swelling, specify location
( ) Back pain ( ) Neck pain ( ) Muscle aches, specify location
( ) Tenderness, specify location
Other findings:

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