NRP/516 Version 2 / 1
University of Phoenix Material
Optional Physical Assessment Form
Name ______(Initials only if used for a class)
General Appearance______
Age ___ Sex ____ Race______Weight ______Height ______BMI ______
SKIN
Color ______Lesions ______
Temperature ______Texture ______Moisture ______Turgor, recoil ______
HAIR
Color ______Distribution ______Hygiene______
NAILS
Color ______Shape ______Adherence to bed ______Texture ______Strength ______
Color return after blanching ______seconds
Absence of clubbing: nail matrix firm______DPD<DIPD ______Angle______
(Distal phalangeal depth less than distal interphalangeal depth)
LYMPHATIC SYSTEM
Indicate if any of the lymph nodes are palpable. If palpable, give a full description: size. Consistency, symmetry, mobility. tenderness, erythema. If not palpable mark 0, if palpable mark +
Lymph nodes
Preauricular______Postauricular______Tonsilar______Occipital ______submaxillary ______
Submental ______Anterior cervical ______Posterior cervical______Supraclavicular______
Infraclavicular ______Axillary ______inguinal______
Palpation of salivary glands
Parotids ______Submaxillary ______
HEAD/FACE
Symmetrical______Position ______Scalp lesions______
Involuntary movements______
Light touch (CN V) ______TMJ for crepitus ______
Masseter muscle strength (CN )______
Symmetrical facial expressions (CN VII) ______
NECK
Range of motion: Flexion ______Extension ______Rotation ______Lateral bending ______
Jugular venous distension with chest at 35-45 degrees elevation ______
Thyroid size ______Texture______Tenderness ______Nodules______
Strength sternocleidomastoid muscle CN XI______Strength trapezius CN XI______
Carotid pulses ______bruit______Tracheal position______
NOSE/SINUSES
External configuration______Patent nares: right _____left _____ able to identify odors CN I______
Color of mucosa ______Septum ______Turbinates visualized ______Discharge______
Frontal Sinuses: palpation ______Transillumination ______
Maxillary Sinuses: palpation ______Transillumination ______
OROPHARYNX
Lips: color______symmetrical ______edema ______lesions ______
Gums: color ______lesions ______adherence to teeth ______inflammation______
Teeth: color ______caries ______missing teeth ______malocclusion ______broken teeth______
Buccal mucosa: color ______lesions or ulcerations ______
Salivary gland orifices visualized: Stensen ducts ______Wharton ducts under tongue______
Tongue: size______distribution of papillae ______lesions ______coating ______
CN XII Strength______ROM ______difficulty with taste CN VII & IX______
Other structures
Hard palate______soft palate ______uvula midline, rises with phonation ______tonsils ______
Posterior pharyngeal wall______
EAR
External ear: size _____ placement in line with the lateral canthus of the eye ______angle of attachment______
lesions ______tenderness on palpation of tragus, external ear, mastoid process ______
Otoscopic examination:
External canal: color ______cerumen ______scaling ______exostoses ______
Tympanic membrane: color _____injection – if present describe location and amount______
Describe visible landmarks: ______
EYE
Eyebrows ______eyelids ______eyelashes ______
Lacrimal apparatus ______conjunctiva______
Sclera ______iris ______limbal margin ______cornea______
Pupils: reaction to light: direct ______consensual ______accommodation______
EOM CN III, IV, VI ______nystagmus ______lid lag ______
Tests for strabismus: tropia ______phoria______
Visual acuity: right______left ______both ______with correction ______+ or –
Peripheral vision CN II temporal: right ______left______Color vision ______
Ophthalmoscopic examination: red light reflex______Color of retina ______
Disc: color ______shape ______margins______C:D ratio______
blood vessels______Artery/vein crossing ______
general background______macula ______
CHEST AND LUNGS
Inspection: Chest symmetrical ______chest wall deformities ______spinal deformities______
Anterior-posterior: transverse diameter ______respiratory rate ______rhythm______
Palpation: tenderness ______respiratory excursion ______tactile fremitus tracheal position______
Percussion notes: ______diaphragmatic excursion______
Auscultation: Breath sounds ______adventitious sounds ______
Voice sounds if suspect consolidation: bronchophony, egophony, whispered pectoriloquy ______
HEART
Inspection: apical pulsation______Jugular venous distension with chest at 35-45 degree angle ______
Palpation: location of apical impulse ______thrills ______carotid arteries______
Auscultation: B/P sitting R ______L ______lying R ______L ______standing R ______L ______
Heart rate______rhythm ______extra beats ______compare SI with S2 apex ______base ______
Describe extra heart sounds if present: S3______S4______clicks______snaps______
Evaluation of heart murmurs: location ______radiation ______grade ______/VI
Systolic or diastolic ______
Palpate peripheral pulses for amplitude and symmetry: carotid______brachial ______radial ______
femoral______popliteal ______,dorsalis pedis ______, posterior tibial ______
Edema: lower extremities ______other locations ______Veins______
BREASTS
Inspection:
Breast: size and symmetry ______contour ______lesions ______retraction / dimpling ______
Nipple: retraction ______discharge ______lesions______
Palpation: breast: consistency ______tenderness______nodules ______
ABDOMEN
Inspection: lesions______scars ______contour ______distention ______aortic pulsations _____
venous pattern ______hair distribution______hernia (raise head & shoulders) ______
Abdominal: superficial reflexes ______
Auscultation: bowel sounds ______Vascular sounds bruit or venous hums______
Percussion: all quadrants______estimate liver size @ mid-clavicular line ______cm.
Spleen: small area of dullness _____ blunt percussion: liver tenderness _____ kidneys CVA tenderness _____
Palpation: light______deep______tenderness______rebound______spleen ______liver______
Kidneys ______Other masses or organomegaly ______diastasis recti ______inguinal nodes __
MUSCULOSKELETAL SYSTEM
Alignment, contour, and symmetry of bone structure______
Muscle characteristics: symmetry ______atrophy ______
ROM and joint function:
neck______shoulder ______elbow ______wrist and hand ______
hip______knee______ankle and foot ______
Muscle strength: Compare right and left against resistance
Upper extremities:
Triceps ______biceps ______
arms: abduction ______adduction ______
wrists ______fingers ______
Lower extremities
Hamstrings ______quadriceps ______
leg: abduction ______adduction ______
plantar flexion ______dorsiflexion ______
NEUROLOGICAL SYSTEM
Mental status: from your observation while taking the history and performing the physical assessment, make a brief statement about each of the following mental status categories:
Appearance and behavior ______
Emotional stability ______
Cognitive abilities ______
Speech and language ______
Cerebellar function ______
Balance: Romberg _____ gait ______tandem walk ______knee bends ______
Coordinated and skilled movements ______
Finger to nose ______finger to nose to finger ______
Rapid alternating movement______heel down shin ______
Sensory perception ______
Primary sensation: tactile discrimination (light touch) ______
Pain, temperature: warm and cold (only if light touch abnormal) ______
Pallesthesia: vibratory sensation______Position sense: proprioception ______
Discriminative sensation: Stereognosis ______graphesthesia ______
Two point discrimination (state where tested) ______distance when 2 points were perceived _____
Superficial reflexes: plantar right ______left ______
Deep tendon reflexes:
Biceps ______
Triceps______
Brachioradialis ______
Patellar______
Achilles ______
FEMALE GENITALIA
Inspection: pubic hair distribution ______lesions ______
Separate labia: clitoris ______labia majora ______labia minora ______urethra ______
Introitus ______perineum ______
Palpation external genitalia
Urethra and Skene’s glands ______Bartholin glands ______pelvic musculature ______
Cystocele ______rectocele ______
Internal examination inspection
Vagina: color ______rugation ______lesions ______discharge ______
Cervix: color ______lesions ______shape of os ______
Surface ectropion, eversion ______Nabothian cysts ______discharge ______
Internal examination palpation
Cervix: consistency ______contour ______mobility ______
Uterus: position ______shape ______size ______
Rectovaginal: adnexa ______rectovaginal septum ______
Rectal masses ______anal sphincter tone ______stool hemoccult ______
MALE GENITALIA
Inspection: pubic hair distribution ______lesions ______
Inspection and palpation external genitalia: urethral orifice _____ penile shaft ______scrotum _____
Palpation of testicles: consistency _____ nodules ______epididymis _____ vas deferens ______
Palpation for hernia: inguinal ______femoral ______
Inspection and palpation of the anus
Pilonidal cyst ____ perianal lesions ______anal sphincter tone _____ bidigital palpable masses ____
Palpation of the rectum: masses ______
Prostate: size ______contour ______median sulcus ______mobility ______
tenderness ______stool hemoccult ______