CHARTING EXAMPLES FOR PHYSICAL ASSESSMENT SKIN, HAIR AND NAIL Skin pink, warm, dry and elastic.

No lesions or excoriations noted. Old appendectomy scar right lower abdomen 4 inches long, thin, and white. Sprinkling of freckles noted across cheeks and nose. Hair brown, shoulder length, clean, shiny. Normal distribution of hair on scalp and perineum. Hair has been removed form legs, axillae. Nails form 160 degree angle at base, are hard, smooth, and immobile. Nailbeds pink without clubbing. Cuticles smooth, no detachment of nailplate. Hands well manicured with clear enamel. HEAD AND NECK Head symmetrically round, hard, and smooth without lesions or bumps. Face oval, smooth, and symmetrical. Temporal artery elastic and nontender. Temporomandibular joint palpated with full range of motion without tenderness. Neck symmetric with centered head position and no bulging masses. C7 is visible and palpable with neck flexion. Has smooth, controlled, full range of motion of neck. Thyroid gland nonvisible but palpable when swallowing. Trachea in midline. Lymph nodes nonpalpable. EYE AND EAR Acuity by Snellen chart O.D. 20/20, O.S. 20/20. Visual fields full by confrontation. Extraocular movements smooth and symmetric with no nystagmus. Evelids in normal position with no abnormal widening or ptosis. No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and smooth. Sclera white with no lesions or redness. No swelling or redness over lacrimal gland. Cornea is transparent, smooth, and moist with no opacities, lens is free of opacities. Irises are round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. Pupils converge evenly. Ears are equal in size bilaterally. Auricles are aligned with the corner of each eye. Skin smooth, no lumps, lesions, nodules. No discharge. Nontender on palpation. Small amount of moist yellow cerumen in external canal. Whisper test : patient repeats 2 syllable word. MOUTH, THROAT, NOSE, AND SINUS Lips pink, smooth, and moist without lesions. Buccal mucosa pink, moist, and without exudates. Stensen/s ducts visible with no redness or swelling. 32 white to yellowish teeth present. Gums pink without redness or swelling. Protrudes geographic tongue in midline with no tremors. Equal bilateral strength in tongue. Ventral surface of tongue smooth and shiny pink with small visible veins present. Frenulum in midline. Soft palate smooth and pink. Tonsillar pillars pink and symmetric. Nose somewhat large but smooth and symmetric. Able to sniff through each nostril. Nasal septum slightly deviated to the left, but does not obstruct airflow. Inferior and middle turbinates dark pink, moist, and free of lesions. No purulent drainage noted. Frontal and maxillary sinuses are nontender to palpation and percussion. THORAX AND LUNG Respirations 18/minute, relaxed and even. Anteroposterior less than transverse diameter. Chest expansion symmetric. No retraction or bulging of interspaces. No pain or tenderness on palpation. Tactile fremitus symmetric. Percussion tones resonant over all lung fields. Vesicular breath sounds auscultated over lung fields. No adventitious sounds present. BREASTS AND LYMPHACIC Bilateral breasts moderate in size, pendulant, and symmetric. Breast skin pale, pink with light brown areola. Nipples everted bilaterally. Free movement of breasts with position changes of arms and hands. No dimpling, retraction, lesions, or inflammation noted. Axillae free of rashes or inflammation.

No masses or tenderness noted on palpation. Bilateral mammary ridge present. No discharge noted from nipples. Axillary ( central, posterior, or anterior) and lateral arm lymph nodes nonpalpable. Demonstrates appropriate technique for BSE. HEART AND NECK VESSELS Carotid pulse equal bilaterally, 2+, elastic. No bruits auscultated over carotids. Jugular venous pulsation disappears when upright. Apical impulse palpated in the fifth ICS at the left MCL. Apical pulse- 70 beats/minute, regular rhythm, S1 heard best at the apex, S2 heard best at the base.

ABDOMEN Skin of abdomen is free of striae, scars, lesions, or rashes. Umbilicus is midline and recessed with no bulging. Abdomen is flat and symmetric with no bulges or lumps. No bulges noted when patient raises head. No peristaltic movements seen. Soft clicks and gurgles heard at a rate of 15 per minute. Percussion reveals generalized tympany over all four quadrants. No tenderness or guarding in any quadrant with light palpation. Umbilicus and surrounding area free of masses, swelling, and bulges. MALE GENITALIA pubic hair growth pattern is normal for adult male: pubic hair and base of penis are free of excoriation and infestation. Circumcised penis is free of rashes, lesions, and lumps and is soft, flaccid and nontender on palpation. Glans is rounded, and free of lesions; urinary meatus is centrally located on glans; no discharge is palpated from urinary meatus. No masses or swelling noted in scrotum and left side hangs slightly lower than right side. Skin is free of lesions and appears rugated and darkly pigmented. Two descended testicles palpated. No swelling, tenderness,or masses palpated along the testicle. No bulges or masses palpated in inguinal or femoral canal. FEMALE GENITALIA Normal hair distribution, no lesions, masses, or swelling. Labia majora pink, smooth, and free of lesions, excoriation, and swelling. Lania minora dark pink, moist, and free of lesions, excoriation, swelling or discharge. No discharge from urethral opening. No malodorous discharge noted from vagina. ANUS AND RECTUM The anal opening is hairless, moist, and closed tightly. Perinanal area is free of redness, lumps, ulcers, lesions, and rashes. No bulging of lesions appear when the patient performs the Valsalva maneuver. Patient can close external sphincter around gloved finger. Anus is smooth, nontender, and free of nodules and hardness. PERIPHERAL VASCULAR arms are equal in size, no swelling, pinkish skin tone, no clubbing of finger tips, warm bilaterally. Capillary refill time less than 2 seconds, radial and brachial pulses strong bilaterally. No epitroclear lymph nodes palpated. Legs are pink in color from toes bilaterally, normal distribution of hair, no ulcers or edema. Legs are warm bilaterally. Femoral, popliteal, dorsalis pedis, and posterior tibial pulses strongly palpated bilaterally. No apparent varicosities or superficial thrombophlebitis noted. MUSCULOSKELETAL Gait smooth, with equal stride and good base of s upport. Full ROM of TMJ with no pain, tenderness, clicking or crepitus. Sternoclavicular joint midline with swelling or redness. Normal curves of cervical, thoracic, and lumbar spine. Paravertebrals nontender. Full smooth ROM of cervical and lumbar spine. Upper and lower extremities symmetric without lesions,nodules, deformities,or swelling. Full smooth ROM against gravity and resistance.

NEUROLOGICAL Cranial Nerves: 1. Identifies correct scents 2. Vision 20/20 OS, 20/20 OD, full visual fields intact. 3,4,6 No ptosis, full extraocular movements (EOM) pupils equally round, react to light and accommodation (PERRLA) 5. Temporal and masseter muscles contract Bilaterally. Able to identify light, sharp, dull touch to forehead, cheek, and chin. Corneal reflex present. 7. Able to smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows, and close eyes against resistance. 8. Wispered 2 syllable words heard bilaterally. 9 and 10. Uvula and soft palate rise symmetrically on phonation. Gag reflex present. Swallows without difficulty. 11. Equal shoulder shrug against resistance; turns head in both directions against resistance. 12. Protrudes tongue in midline with no tremors, able to push tongue blade to right and left with no difficulty. Motor and Cerebellar System No atrophy, tremors, weakness, full ROM of all extremities. No fasciculations, tics, or tremors. Gait and tandem walk normal and steady. Negative Romberg test. Performs repetitive alternating movements, finger to nose at smooth, good pace. Runs each heel down each shin with no deviation. Sensory System Identifies light touch, dull and sharp sensations to trunk and extremities. Vibratory sensation, stereognosis, graphesthesia, two-point descrimination intact. Reflexes Reflexes 2+ bilaterally, except Achilles 1+. No Babinski present.

Checklist HEAD, FACE

Inspect & palpate head for shape, symmetry, lumps. Note hair color, texture, distribution. Palpate temporal artery. Palpate & percuss frontal & maxillary sinuses. Check nasal patency and with pen light. Ask about smell (CN 1). Palpate masseters - clenched teeth -(CN 5, 7) Test light facial sensation (CN 7).

EYES
y y y y y

Inspect eyelids and external structures. o size, shape and symmetry of eyebrows, eyelids, eyelashes. Inspect conjunctiva, sclera for color variations, PERRLA. o Pupillary reaction to light. Check 6 cardinal fields (CN 3, 4, 6). Visual fields & extraocular muscle function. Check vision (CN 2)

EAR
y y y

Inspect & palpate ear (note size, shape, skin condition, tenderness) Inspect for ear drainage. Hearing voice test (CN 8).

JAW, MOUTH
y y y y

Palpate temporomandibular joint, inspect teeth, gums, tongue, palate, and uvula. Check tonsil fossa Say ah (CN 9, 10), swallow reflex intact. Pt. Protrudes tongue (CN 12).

NECK
y y y y y y y y y

Inspect & palpate neck. Note trachea midline. Check neck ROM. Palpate thyroid lightly. Palpate carotids (separately). Auscultate for bruits. Assess apical carotid pulse. Palpate cervical lymph nodes (identify all chains). Shrug shoulders (States CN 11). Assess skin turgor. Pinch up skin on upper chest area.

UPPER EXTREMITIES
y y y y y y y

Inspect arms skin color, hair distribution, Assess nails texture, contour & color, capillary refill. Assess ROM and strength (hand grips). Palpate & assess radial pulses (rate, rhythm, & amplitude). Assess radial apical pulse. Assess capillary refill nails. Assess deep tendon reflexes (biceps, triceps).

CHEST (Lungs)
y y y y y y y y y

Inspect post., lat. & ant. chest. Observe rate and rhythm of respirations. Check expansion at T9-T10. Assess tactile fremitis. Percuss side to side (resonance). Auscultate anterior apex to base, side to side for adventitious sounds. Auscultate posterior apex to base, side to side for adventitious sounds. o Note Adventitious sound. Note spinal curvatures. Palpate axillary lymph nodes. Ask about breast self-exam (females).

HEART
y y y y

Inspect for pulsations & palpate at PMI. Auscultate at Aortic, Pulmonic, Tricuspid, Mitral (A+ To Me). Auscultate apical-radial, & apical-carotid (amplitude, rhythm, rate). Identify S1, S2. Listen for murmurs, clicks. Listen for S3, S4 gallups.

ABDOMEN
y y y y y y y y

Inspect color, contour, pulsations. Note scars Auscultate bowel sounds over 4 quadrants Auscultate aortic sounds. Check for ascites. Lightly palpate 1cm. over 4 quadrants. Percuss 4 quadrants (tympany). Check for hernias (umbilical). Assess superficial reflex.

LOWER EXTREMITIES
y y y y y

Assess skin of legs, hair distribution. Assess ROM and strength. Assess deep tendon reflexes (patellar, achilles). Palpate & assess posterior tibial, and dorsalis pedis pulses. Assess Homans sign.

y y y y y

Check for edema. Assess babinski reflex. Assess ankle ROM and strength. Inspect toes & capillary refill. Check skin sensation (evaluate based on dermatome levels).