Hi, my name is _____. I am a student nurse and I here to do your
physical assessment
Could you verify you name and date of birth for me, please?
Check wristband
I will begin by asking a few questions
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General Health - weight gain/loss, fatigue
Skin, Hair, Nails - Hx of skin disease, rash
Head - headache, dizziness
Eyes - difficulty with vision , eye pain
Ears - earaches, infections
Nose and Sinuses - sinus pain, nosebleeds
Mouth and Throat - mouth pain, frequent sore throat
Neck - pain, limitation of motion
Respiratory - wheezing, SOB
Cardiovascular - chest pain, palpitation
Peripheral Vascular - numbness/tingling, swelling of legs
Gastrointestinal - constipation , diarrhea
Urinary - urgency, nocturia
Musculoskeletal - pain, stiffness
Neurological - fainting, blackouts
Hematological - bleeding tendency, excessive bruising
General Appearance:
 Could you please state your name and age?
 Do you know where you are?
 Why you are here
 What day of the week it is?
Head and face:
 Inspect skin
 Inspect for face expression/Inspect for facial symmetry.
 Palpate TMJ as person open and closes mouth
Eyes:
 Inspect external eye structures
 Inspect conjunctiva
 Inspect sclerae
 Inspect corneas
 Inspect irises
 PERRLA (CN III, IV, VI)
Ears:
 Inspect external structure(s) of
the ear
 Test hearing using whispered
voice test (CN VIII)
 Inspect skin
Mouth :
 Inspect Lips
 Inspect buccal mucosa
 Inspect teeth
 Inspect gums
 Inspect tongue
 Inspect floor of mouth
 Inspect palate
 Inspect uvula
 Note mobility of uvula on
phonation of “ah” (CN IX and
X)
 Grade tonsils if present
Neck:
 Inspect for symmetry
 Inspect for lumps
 Inspect for pulsations
 Inspect skin
 Inspect and palpate carotid
pulse one side at a time
 Palpate trachea
Chest Respiratory:
Anterior:
 Inspect respirations
 Inspect skin characteristics
 Palpate lumps
 Palpate tenderness
 Palpate tactile fremitus
 Auscultate breath sounds
Posterior & lateral:
 Inspect for configuration of
thoracic cage
 Inspect skin characteristics
 Inspect symmetry of shoulders
 Palpate for symmetric expansion
 Palpate for lumps
 Palpate for tenderness
 Percuss lung fields
 Auscultate breath sounds
Chest Heart
 Inspect skin
 Inspect precordium for
pulsations
 Inspect for heaves
 Auscultate apical heart rate
and rhythm x10 seconds
 Auscultate heart sounds in 5
precordial sites with bell and
diaphragm
Abdomen
 Inspect contour
 Inspect for symmetry
 Inspect skin characteristics
 Inspect umbilicus
 Inspect for pulsations
 Auscultate bowel sounds
 Auscultate for bruit over aorta
 Palpate using light palpation
 Palpate using deep palpation
Lower Extremities
Upper Extremities
 Test ROM and muscle strength Test ROM and muscle strengthhips, knees, ankles
shoulders, elbows, wrists
 Test foot pushes
 Test hand grips
 Inspect symmetry
 Palpate for temperature
 Inspect skin characteristics
 Check capillary refill
 Inspect hair distribution
 Palpate radial pulses
 Palpate for temperature
 Palpate brachial pulses
 Palpate posterior tibial pulses
 Inspect nails
 Palpate dorsalis pedis pulses
 Inspect skin characteristics
 Palpate for pretibial edema
 Palpate skin turgor
Neurological
 Test for superficial pain
sensation
 Test for light touch sensation
 Gait (regular, heel-to-toe, on
the toes, on the heels)
 Romberg sign
Spine
 Inspect skin characteristics
 Palpate spinous processes for
tenderness
 Check spine for alignment