• Physical Assessment Guide
• General Instructions
• Overall Appearance Inspection
• Skin Inspection and Palpation
• Head Inspection and Palpation
• Eyes Inspection and Palpation
• Ears Inspection and Palpation
• Nose and Sinuses Inspection and Palpation
• Mouth and Pharynx Inspection
• Neck Inspection and Palpation
• Thorax and Lungs Inspection, Palpation, Percussion, and Auscultation
• Breasts and Axillae Inspection and Palpation
• Heart and Peripheral Vascular Inspection, Percussion, Auscultation, and Palpation
• Abdomen Inspection, Auscultation, Percussion, Palpation
• Musculoskeletal Inspection and Palpation
• Genitourinary and Rectum Inspection
• Neurologic
• Mental Status

Name ________

Date ________

Age ______

Height ________

Weight ________

BMI ________

Waist Circumference ________

Frontal-Occipital Circumference ________

Vital Signs:

T ________

P ________

R ________

BP:

Sitting ________

Standing ________

Lying ________

Physical Assessment Guide

General Instructions

Use this guide for suggested descriptive terminology for documentation on the Sample Adult Physical Assessment Form.

Be specific, descriptive, and objective. Avoid such terms as "normal," "within normal limits," "good," "fair," "O.K.," and so forth. Describe what you observe rather than make inferences or judgments.

Overall Appearance Inspection

Gender: Male/female.

General grooming: Clean? hair combed? makeup?

Position/posturing: Supine? prone? rigid? opisthotonos? erect? slumped?

Body size: Thin? overweight? obese? emaciated? flabby? weight proportionate to height? mesomorph? endomorph? ectomorph?

Facial expressions: Smiling? frowning? blank? apathetic?

Body language: Eye contact? no eye contact? arms folded over chest?

Other observations: Restless? fidgeting? lying quietly? listless? trembling? tense?

Skin Inspection and Palpation

Color and vascularity: Pink? tan? brown? dark brown? grayish? pasty? yellowish? flushed? jaundiced?

Turgor and mobility: Elastic? nonelastic? tenting? wrinkled? edematous? tight?

Temperature and moisture: Cold? cool? warm? hot? feverish? moist? dry? clammy? oily? sweating? diaphoresis?

Texture: Smooth? rough? fine? thick? coarse? scaly? puffy?

Nails: Clean? manicured? smooth? rough? dry? hard? brittle? splitting? cracking? angle of nail bed? clubbing? curved? flat? thick? yellowing? paronychia? Nail beds and lunule: Pale? pink? cyanotic? red? shape of lunule? blanching? spooning?

Body hair growth: Color? thick? thin? coarse? fine? location and distribution on body? hirsutism?

Skin integrity: Intact? not intact? Lesions, birthmarks, moles, scars and rashes (describe shape, size, and location): Nevi? fissures? maculas? papules? pustules? nodules? bullae? cysts? carbuncle? wheals? erythema? excoriation? desquamation? abrasions? cherry angiomas? lentigines? purpura? keratoses? seborrheic keratoses? bruises? insect bites? crusts? warts? pimples? blackheads? bleeding? drainage? lacerations? scaly? ulcers? lichenification?

Head Inspection and Palpation

Shape: Round? oval? square? pointed? normocephalic?

Face: Oval? heart-shaped? pear? long, square? round? thin? high cheekbones? symmetrical?

Sensation (trigeminal—CN V): Sensation on three branches? clenched teeth?

Facial CN VII: Facial expressions, smiles?

Hair: Color and growth: coarse? fine? thick? thin? sparse? alopecia? long? short? curly? straight? permed? glossy? shiny? greasy? dry? brittle? stringy? frizzy?

Condition of scalp: Clean? scaly? dandruff? rashes? sores? drainage?

Masses and lumps: Describe location and shape; measure size.

Eyes Inspection and Palpation

Eyebrows: Color and shape: Alignment? straight? curved? thick? thin? sparse? plucked? scaly?

Eyelashes: Long? short? curved? none? artificial?

Eyelids: Dark? swollen? inflamed? red? stye? infected? open and close simultaneously? ptosis? entropion? ectropion? lid lag? xanthomas?

Shape and appearance of eyes: Almond? rounded? squinty? prominent? exophthalmic? sunken? symmetrical? bright? clear? dull? tearing? discharge? (serous? purulent?) exotropia? esotropia? nystagmus? strabismus?

Sclera: White? cream? yellowish? jaundiced? injected? pterygium?

Conjunctivae: Pale pink? pink? red? inflamed? nodules? swelling?

Iris: Color and shape: Round? not round? coloboma? arcus senilis?

Cornea: Clear? milky? opaque? cloudy?

Pupils (oculomotor—CN III) [PERRLA]: Size and shape: (Measure in millimeters) Round? not round? (describe) Equality: Symmetrical? anisocoria? right larger than left? left larger than right? convergence? Reaction to light and accommodation? consensual reaction?

Extraocular movements (oculomotor), trochlear, (abducens—CN III, IV, VI): Intact?

Lacrimal glands: Tender? nontender? inflamed? swollen? tearing?

AIDS: Glasses? contact lenses? prosthesis?

Visual fields (optic—CN II): Intact?

Vision (optic—CN II): Reads newsprint? reports objects across room?

Ears Inspection and Palpation

Pinnae:Size and shape: large? small? in proportion to face? protruding? oval? large lobes? small lobes? symmetrical? right larger than left? left larger than right? pinnae irregular? color? skin intact? redness? swelling? tophi? cauliflower ear? furuncles? Darwin's tubercle?

Level in relation to eyes: Top of pinnae level with outer canthus of eyes? top of pinnae lower than outer canthus of eyes? top of pinnae higher than outer canthus of eyes? Canal: Clean? discharge? (serous? bloody? purulent?) nodules? inflammation? redness? foreign object? Cilia: Present/absent? Cerumen: Present/absent? color? consistency?

Tympanic membrane: Color? pearly white? injected? red? inflamed? discharge? cone of light? landmarks? scarring? bubbles? fluid level?

Hearing (auditory—CN VII): Right—present/absent? left—present/absent? hears watch tick? hears whisper? responds readily when spoken to? Weber: Lateralizes equally? to left/right side? Rinne: Air conduction > bone conduction 2:1? Hearing aid: Right/left.

Nose and Sinuses Inspection and Palpation

Size and shape: Long? short? large? small? in proportion to face? flat? broad? broad based? thick? enlarged? nares symmetrical/asymmetrical? pointed? swollen? bulbous? flaring of nostrils?

Septum: Midline? deviated right/left? perforated?

Nasal mucosa and turbinates: Pink? pale? bluish? red? dry? moist? discharge? (purulent? clear? watery? mucus?) cilia present/absent? rhinnitis? epistaxis? polyps?

Patency of nares: (close each side and ask patient to breathe) Right—patent/partial obstruction/obstructed? left—patent/partial obstruction/obstructed?

Olfactory (CN I): Correctly identifies odors?

Sinuses: Tender? nontender? transillumination?

Mouth and Pharynx Inspection

Lips: Color: Pink? red? tan? pale? cyanotic? Shape: Thin? thick? enlarged? swollen? symmetrical/asymmetrical? drooping left side? drooping right side? Condition: Soft? smooth? dry? cracked? fissured? blisters? lesions? (describe)

Teeth: Color and condition: White? yellow? grayish? spotted? stained? darkened? pitting? notched? straight? crooked, protruding? separated? crowded? irregular? broken? notching? peglike? loose? dull? bright? edentulous? malocclusion? presence of dental caps or other appliances? Caries and filings: Number and location? Dental hygiene: Clean? not clean?

Breath odor: Sweet? odorless? halitosis? musty? acetone? foul? fetid? odor of drugs or food? hot? sour? alcohol?

Gums: Pink? firm? swollen? bleeding? sensitive? gingivitis? hypertrophy? nodules? irritated? receding? moist? ulcerated? dry? shrunken? blistered? spongy?

Facial and glossopharyngeal (CN VII and IX): Identifies taste?

Tongue: Macroglossia? microglossia? glossitis? geographic? red? pink? pale? bluish? brownish? swollen? clean? thin? thick? fissured? raw? coated? moist? dry? cracked? glistening? papillae?

Hypoglossal (CN XII): Tongue movement: symmetry? lateral? fasciculation?

Mucosa: Color? leukoplakia? dry? moist? intact? not intact? masses? (describe size, shape, and location) chancre?

Palate: Moist? dry? color? intact? not intact?

Uvula: Color? midline? Remains at midline when saying "ah"? gag reflex present?

Pharynx: Color? petechia? injected? beefy? dysphagia?

Tonsils: Present/absent? cryptic? beefy? size 1+ to 4+?

Temporomandibular joint: Fully mobile? symmetrical? tenderness? crepitus?

Neck Inspection and Palpation

Appearance: Long? short? thick? thin? masses? (describe size and shape) symmetrical? not symmetrical?

Thyroid: Palpable? nodules? tender?

Trachea: Midline? deviated to right/left?

Lymph nodes: (Occipital, preauricular, postauricular, submental, submaxillary, tonsilar, anterior cervical, posterior cervical, superficial cervical, deep cervical, supraclavicular): Nonpalpable? tender? lymphadenopathy? shotty? hard? firm?

Thorax and Lungs Inspection, Palpation, Percussion, and Auscultation

Respirations: Rate? tachypnea, eupnea, bradypnea? apnea? orthopnea? labored? stertorous? Rhythm: Regular/irregular? inspiration time greater than expiration time? expiration time greater than inspiration time? spasmodic? gasping? orthopneic? deep? eupneic? shallow? flaring of nostrils with respirations? symmetrical/asymmetrical? right thorax greater than left? left thorax greater than right? ratio of AP diameter to lateral diameter between 1:2 and 5:7? ribs sloped downward at 45-degree angle? well-defined costal space? accessory muscles used? pigeon chest? funnel chest? barrel chest? abdominal or chest breather? skin intact? lesions? color? thin? muscular? flabby?

Posterior thorax: Tenderness? masses? Respiratory excursion: Symmetrical? asymmetrical? no respiratory movements on right/left? subcutaneous emphysema? crepitus? fremitus? estimation of level of diaphragm? spine alignment? tenderness? CVA tenderness? resonance? dull? hyperresonance? diaphragmatic excursion 3 to 5 cm? comparison of one side to the other? suprasternal notch located? costochondral junctions tender? chest wall stable? vocal fremitus?

Lung auscultation: Vesicular? bronchovesicular? bronchial? whispered pectroliloquy? adventitious sounds? rales? rhonchi? wheezes? crackles? rub? bronchophony? egophony?

Breasts and Axillae Inspection and Palpation

Breasts: Male? female? present/absent? color? large? small? well developed? firm? pendulous? flat? flabby? symmetrical/asymmetrical? dimpling? thickening? smooth? retraction? peau d'orange? venous pattern? tenderness? masses? (describe) gynecomastia?

Nipples: Present/absent? circular? symmetrical/asymmetrical? inverted? everted? pale? brown? rose? extra nipples? discharge? deviation? supernumerary?

Axillae: Shaved/unshaved? odor? masses or lumps? (describe size and shape)

Lymph nodes: (Lateral, central, subscapular, pectoral, epitrochlear) palpable? tender? shotty?

Heart and Peripheral Vascular Inspection, Percussion, Auscultation, and Palpation

Heart: Precordial bulge? abnormal palpations? Point of maximum intensity? thrills? heave or lift with pulsation? S₁ loudest at apex? S₂ loudest at base? S₃? S₄? splits? clicks? snap? rub? gallop? Murmurs: Systolic? diastolic? holosystolic? harsh? soft? blowing? rumbling? grading 1 through 6? high pitch? medium pitch? low pitch? radiating? pacemaker?

Carotid pulse: Note: Do not check both right and left carotid pulses simultaneously. Volume: Bounding? forceful? strong? full? weak? feeble? thready? symmetrical? right less than left? left less than right? Rhythm: Regular? irregular? symmetrical? asymmetrical? bruits present? absent?

Apical pulse: Record rate; tachycardia? bradycardia/pounding? forceful? weak? moderate? regular/irregular?

Peripheral pulses: (Do not count rate of these pulses except radial.) Record character, volume, rhythm, and symmetry of brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses. Volume: Full? strong? forceful? bounding? perceptible? imperceptible? weak? thready? symmetrical/asymmetrical? right greater than left? left greater than right? Rhythm: Regular? irregular? symmetrical? asymmetrical? Symmetry: Record as symmetrical, right greater than left or left greater than right? Pulse deficit, pulse pressure, BP in both arms, BP lying, sitting, and standing if applicable. Jugular venous distention? (Record centimeters above level of sternal angle.)

Abdomen Inspection, Auscultation, Percussion, Palpation

Contour: Irregular? protruding? enlarged? distended? scaphoid? concave? sunken? flabby? firm? flat? flaccid?

Skin: Color; intact? not intact? shiny? smooth? scars? lesions? (describe size, shape, and type of lesion) striae? umbilicus?

Bowel sounds: Present? absent? hyperactive? high-pitched tinkling? gurgles? borborygmus?

Percussion: Tympanic? dull? flat? (describe where) liver size 6 to 12 cm? splenic dullness 6th to 10th rib? ascites?

Palpation: Splenomegaly? hepatomegaly? organomegaly? masses? aortic pulse? diastasis recti? tenderness? bulges? lower pole of kidneys palpable? inguinal or femoral hernia? inguinal nodes? (describe)

Musculoskeletal Inspection and Palpation

Back: Shoulders level? right shoulder higher than left? left shoulder higher than right? alignment? lordosis? scoliosis? kyphosis? ankylosis?

Vertebral column alignment: Straight? lordosis? scoliosis? kyphosis?

Joints: Redness? swelling? deformity? (describe) crepitation? size? symmetry? subluxation? separation? bogginess? tenderness? pain? thickening? nodules? fluid? bulging? artificial?

Range of motion: Describe as full, limited, or fixed; estimate degree of limitation; assess range of motion of neck, shoulders, elbows, wrists, fingers, back, hips, knees, ankles, toes.

Extremities: Compare extremities with each other; describe color and symmetry. Temperature: hot, warm, cool, cold, moist, clammy, dry. Muscle tone descriptors are firm, muscular, flabby, flaccid, atrophy? fasciculation? tremor?

Lower extremities: Symmetry? (Describe any variations from normal.) abrasions? bruises? swollen? edema? rashes/lesions? (describe) prosthesis? varicose veins?

Genitourinary and Rectum Inspection

Rectum: Hemorrhoids? inflammation? lesions? skin tags? fissures? excoriation? swelling? mucosal bulging? retrocele?

Female genitalia: Pubic hair distribution and color? nits? pediculosis? lesions? nodules? inflammation? swelling? pigmentation? dry? moist? shriveled, atrophied or full labia? discharge? (describe) odor? asymmetry? varicosities? uterine prolapse? smegma? rash?

Male genitalia: Pubic hair distribution and color? nits? pediculosis? circumcised? uncircumcised? phimosis? epispadias? hypospadias? smegma? priapism? varicocele? cryptorchism, hydrocele? swelling? redness? chancre? crusting? rash? discharge? (describe) edema? scrotal sack rugated? atrophy?

Neurologic

Describe tics, twitches, paresthesia, paralysis, coordination.

Gait: Balanced? shuffling? unsteady? ataxic? parkinsonian? swaying? scissor? spastic? waddling? staggering? faltering? swaying? slow? difficult? tottering? propulsive?

Accessory (CN XI): Shrugs shoulder? symmetry?

Reflexes: Report as present or absent.

Coordination: Report as to test done.

Cranial nerves: May be reported here.

Mental Status

Level of alertness: Alert? stuporous? semicomatose? comatose?

Orientation: Oriented to time, place, and person? confused? disoriented? If confused, check orientation as follows.

• Time: Ask patient year, month, day, date.
• Place: Ask paient's residence address, where she or he is now.
• Person: Ask patient's name, birthday.

Memory: Recent memory: Give patient short series of numbers and ask patient to repeat those numbers later. Long-term: Ask patient to recall some event that happened several years ago.

Language and speech: Language spoken? Speech: Slurred? slow? rapid? difficulty forming words? aphasia?

Responsiveness: Responds appropriately to verbal stimuli? responds readily? slow to respond?