Emergency Medical Services Program
University of Wisconsin Hospital and Clinics
Physical Assessment Suggestions
Neurological:
€ Mental Status:
o AVPU: Alert, Verbal, Pain, Unresponsive
o Alert and Oriented x4 (person, place, time, situation)
o Appropriate to situation
o Memory intact
o Glasgow Coma Scale
€ Generalized:
o Dizziness, ataxia, confused, Agitated
o Able to follow commands
€ Eyes
o PERRL
o Vision Changes
€ Mood:
o Affect
o Hallucinations
€ Cincinnati Prehospital Stroke Scale
o LAST TIME SEEN ACTING NORMAL/APPROPRIATE
o Speech:
§ Normal, Age appropriate, slurred, incoherent, aphasic, language barrier
o Facial droop and symmetry
o Arm drift
******* Significant medications that affect neurological system
******* Appropriate interventions
o ICP monitor, Lumbar puncture, Cerebral Spinal Fluid (CSF) assessment, VP
shunt, etc.
Cardiovascular:
€ Vital signs:
o Cap Refill: Normal or delayed____________ (seconds)
o BP: postural changes / orthostatic hypotension
o HR: rate, regularity, quality
€ ECG Rhythm: Rate, Cardiac Rhythm, T-waves, ST abnormalities
€ Chest Pain: (O-P-Q-R-S-T)
€ JVD present
€ Peripheral Vascular:
o Edema location: feet, legs, abdomen, arms
o Calf tenderness
o Pulses present x4 extremities
€ Heart sounds: normal or abnormal
€ Skin (note: if you address this data here you do NOT need to repeat under skin/MS)
o Color
§ Pink
§ Pale
§ Cyanotic
§ Ecchymosis
o Character:
§ Dry
§ Warm
§ Hot. Febrile
§ Cool
§ Diaphoretic
******* Significant medications that affect cardiovascular system
o Inotropic agents, vasopressor agents, B-Blockers, etc
******* Appropriate interventions
o IVs including location, IV fluid and rate
o Cardiac Catheterization, Intra aortic balloon pump (IABP)
Respiratory:
€ Airway:
o Patent
o Accessory muscle use
o Nasal flaring
o Stridor
o Grunting
o Retractions
o Obstructed
o Intubated (ETT size and marking at teeth or lips)
€ Normal or Distress
o Labored
o Deep
o Shallow
o Apnea
o Dyspnea
o Kussmaul
o Hyperventilation
o Short of breath
€ Rate
€ Breath Sounds (right and left)
o Accessory muscle use
o Clear
o Decreased
o Rales
o Wheezing
o Rhonchi
o Absent
€ Cough:
o Dry
o Productive
o Sputum color
€ General Assessment
o Color of nailbeds, lips, mucous membranes
o Chest Symmetry
o Tracheal Position
o Position of comfort
******* Significant medications that affect respiratory system
o Albuterol, atrovent, etc.
******* Appropriate interventions
o Ventilator settings, Suctioning via ETT (note secretions)
GI/GU:
€ Gastrointestinal
o General Assessment:
§ Nausea, Vomiting, Diarrhea
§ Pain (O-P-Q-R-S-T)
Position of comfort
Change in eating or drinking patterns
Last bowel movement
• Change in consistency, color
o Bowel Sounds
§ Present
§ Absent
§ Hypoactive
§ Hyperactive
o Abdomen
§ Soft
§ Round
§ Flat
§ Distended
§ Rigid
§ Guarded
§ Rebound tenderness
§ Tender
§ Masses present
******* Significant medications that affect gastrointestinal system
o Kayexelate, enemas, Maalox, Mylanta, Omeprazole, etc.
******* Appropriate interventions
o NG/OG tubes, G-Tubes, Ostomies
§
§
§
Genitourinary:
o Flank pain (right or left) (O-P-Q-R-S-T)
o Dysuria
o Frequency
o Bladder distension
o Incontinent
o Discharge
o Urine:
§ Amount
§ Sediment
§ Color (describe)
• Hematuria, amber, yellow, orange
o Pediatrics:
§ Diaper Assessment
§ Frequency of diaper changes
o Position of comfort
******* Significant medications that affect genitourinary system
o Diuretics, etc.
******* Appropriate interventions
o Foley, Hemodialysis
€
€
GYN/OB: (assess in all females with abdominal pain)
o Last menstrual period
o Bleeding
o Discharge
o Menopause
o Hysterectomy
o Pregnant?
§ Gravada_________Para___________
§ Estimated Due Date
§ Prenatal care
§ Preexisting conditions (diabetes, HTN)
§ Contractions (time apart and duration)
******* Significant medications that affect reproductive system
o Magnesium, terbutaline, etc.
******* Appropriate interventions
o ?
Skin/Musculoskeletal:
€ Skin (note: if you address this data here you do NOT need to repeat under CV)
o Color
§ Pink
§ Pale
§ Cyanotic
§ Ecchymosis
o Character:
§ Dry
§ Warm
§ Hot. Febrile
§ Cool
§ Diaphoretic
o Rash (describe)
o Wounds (describe)
o Significant scarring (describe)
******* Significant medications that affect Integumentary system
o Benadryl, hydrocortisone, etc.
******* Appropriate interventions
o Suturing, drains, etc.
Musculoskeletal
o Deformities
o Injuries current and previous)
o Movement (range of motion)
o Strength
o 5 Ps
§ Pain (O-P-Q-R-S-T)
§ Pallor
§ Pulses
• Comparison pulse checks (Right to left)
§ Paresthesia
§ Paralysis
******* Appropriate interventions
o Traction, surgical procedures to fix injury
€
Additional Comments:
******* The starred items will not need to be addressed for the first assessments. As you
become more comfortable with your rotations in the hospital and your assessments, we will ask
for these starred items as applicable.
physical assessment suggestions