NUR 203: PHYSICAL ASSESSMENT
FINAL PHYSICAL EXAMINATION: PERFORMANCE CHECKLIST
PART II:
Comments
Wash Hands and Introduce Self
PATIENT SEATED:
Lean Forward and Auscultate Base of Heart (Aortic and
Pulmonic Regions)
PATIENT SUPINE:
Inspect Precordium
Palpate General Precordium (4 regions: aortic, pulmonic,
LSB, and apex)
Palpate Apical Impulse
Auscultate Apical Pulse for 30 seconds (evaluate rate and
rhythm)
Use Diaphragm to Evaluate for Murmurs in Aortic,
Pulmonic, Tricuspid, and Apical/Mitral Regions
(identify/name them)
Use Bell to Evaluate for Murmurs (as noted above; no
need to rename)
PATIENT IN LEFT LATERAL RECUMBENT
POSITION:
Listen with Bell at Apex
PATIENT SUPINE:
Inspect Abdomen (examiner at patient’s rt. Side)
Auscultate Bowel Sounds (beginning in RLQ)
Auscultate Vascular Sounds: Aortic & Bilateral Renal
Arteries
Percuss all 4 quadrants
Percuss liver (percuss up from tympany, noting dullness;
do not measure)
Palpation: Light then Deep
Palpate Liver, Right Kidney, and Aorta
Palpation of Hips (bilaterally)
ROM of Hips (bilaterally) (flexion with knee straight 90;
with knee flexed 120; internal rotation 40; external
rotation 45; abduction 45; adduction 30
Inspect Lower Extremities for symmetry, skin lesions,
hair distribution (bilaterally)
Palpate for Temperature and Pretibial Edema
(bilaterally)
Palpate Pulses: Popliteal, D-P, and P-T bilaterally and
compare
SUB-TOTAL POSSIBLE 50
Have to say aortic and pulmonic, use diaphragm
S1, S2 heard nice and regular
With light, no heaves or lifts or pulsations, skin intact and
even tone.
LSB=left sternal border, apex is in left fifth intercostal space.
No thrills
Short gentle tab, 1 to 2 cm
Use diaphragm, rate 72, rhythm regular.
S1 S2 heard nice and regular, no extra beats, no murmurs,
no s3 s4.
I will switch to the bell and listen to all 4 areas again
Keep your stethoscope in the mitral region using bell and
position patient to the left side. S1 S2 nice and regular, no
murmurs, no extra beats, no s3 s4
Flat, symmetric, umbilical cord inverted and midline, skin
intact even tone, no scars
Nice and active times 4
No bruit
Tympany predominates
Dullness at right costal margin
Soft, no guarding; no organomegaly, no pain
Non palpable, aorta 3 cm OR
Liver—smooth regular ridge
Kidney—right round smooth mass
Aorta—2 cm
Nice, stable, warm, dry.
Full range of motion
Symmetric, hair evenly distributed, skin intact, no lesions.
Warm, no edema.
2+ bilaterally
STUDENT SCORE
/50
PART II (continued):
Comments
PATIENT SITTING:
Inspection and palpation of knees (bilaterally) (ROM
is done later)
Inspection and palpation of ankles and feet
(bilaterally)
ROM ankles/feet (bilaterally) (dorsiflexion 20; plantar
flexion 45; eversion 20; inversion 30)
Strength: dorsiflexion and plantar flexion against
resistance (bilaterally)
Separate Toes and Inspect Skin for lesions/rashes
PATIENT SITTING:
Sensory Function of CN V (cotton ball to 3 facial
regions bilaterally) close eyes
Sensation (Dull/Sharp) to Arms and Legs (all 4
extermeties)
Position Sense of One Finger Bilaterally (kinesthesia)
Stereognosis Bilaterally
Graphesthesia Bilaterally
Cerebellar Function Upper Ext: Rapid Alternating
Movement (hand slap or thumb to fingers)
Finger-to-Nose Test
Cerebellar Function Lower Ext: Heel Down Shin
DTRs Bilaterally (Name them):
Biceps, Triceps, Brachioradialis, Patellar/Quadriceps,
and Achilles
Plantar Reflex/Babinski Sign Bilaterally
PATIENT STANDING:
Romberg (feet together; arms at sides; examiner
stands close)
Inspection of the hips (bilaterally)
ROM of Knees bilaterally (hyperextension 15; flexion
130)
ROM Spine:
Flexion, Hyperextension, Bilateral Rotation, and
Bilateral Lateral Bend/Tilt
Scoliosis Evaluation (examiner positioned behind
client; client’s back in flexion)
General Gait Evaluation
Tandem/Heel-Toe Walk
ORGANIZATION
Symmetric, skin intact, warm, dry, stable
Stable, warm, dry, symmetric, skin intact
Full range of motion
5+ strength
Intact, no fungus, no lesions
Able to feel sensations accurately in 6 places in the face.
Able to accurately describe sensations
Able to accurately identify the finger movements
Able to accurately identify the object
Able to accurately identify the numbers
Smooth accurate coordinated movements
Smooth accurate coordinated movements
Smooth accurate coordinated movements
Biceps 2+ bilaterally, Triceps 2+ bilaterally, Brachioradialis 2+ bilaterally,
Patellar/Quadriceps 2+ bilaterally, and Achilles 2+ bilaterally
Negative babinski
Negative romberg
Iliac crest symmetric, skin intact
Full range of motion
Full range of motion
No scoliosis
SUB-TOTAL POSSIBLE 50
STUDENT SCORE
/50
TOTAL POSSIBLE 50 + 50 = 100
STUDENT SCORE
/100