Physical Assessment Cheat Sheet

Physical Assessment Practical Cheat Sheet            Name/wristband (DOB)/ allergies Wash hands, infection control A&O questions o person, place, time, President Vital Sign o just state if it is high or low, normal range Mood/general wellbeing o How are you feeling today? Pain? o OLD CHART Skin inspection o Warm, dry, and intact o Inspect hair and scalp o Skin turgor test on back of hand o Inspect for edema, clubbing Ears inspection o palpate ear for abnormal findings o whisper test (stand behind patient and whisper “hello”)- CN 8- Vestibulocochlear Nerve: Equilibrium and hearing o palpate pinna, tragus, mastoid process Mouth inspection o Moist and intact. o Can they swallow? o CN  9. Glossopharyngeal Nerve: Swallowing, sense of taste, and saliva secretion  11. Accessory Nerve: Movement of neck and shoulders  12. Hypoglossal Nerve: Movement of tongue, swallowing, and speech o Say awe, inspect tonsils- should be grade 0 Palpate lymph nodes- Non palpable. Is this the right order? o Posterior auricular o Occipital o Superficial cervical o Tonsillar o Parotid o Preauricular o Submandibular o Submental o Deep cervical o Posterior cervical o Supraclavicular Auscultate carotids arteries for buits and palpate carotid pulses o With bell of steth.                o one at a time, compare with radial pulse, in sync, even, and regular Asses for JVD o position at 45* angle o *palpate thyroid for placement Test CN 1 o Olfactory- use alcohol pad for smell Vision exam o Snellen chart- 20 ft away? o CN 2- optic PERRLA o pupils, equal, round, reactive to light, accommodating to light, constriction appropriate 6 fields of gaze o Make and H o CN  3. Oculomotor Nerve: Eyeball and eyelid movement  4. Trochlear Nerve: Eye movement  6. Abducens Nerve: Eye movement Test CN facial-7 o Smile/ frown/ puff cheeks/raise eyebrows o CN 5- trigeminal-Touch penlight to face Whisper test and Romberg test, o test gait and balance o CN 8- Vestibulocochlear Nerve: Equilibrium and hearing o Romberg-Negative o Whisper test- 2ft away Tongue movement o CN 9 Glossopharyngeal Nerve: Swallowing, sense of taste, and saliva secretion o CN 10 Vagus Nerve: Smooth muscle sensory and motor control in throat Test trapezius muscle o CN 11 Accessory Nerve: Movement of neck and shoulders o Raise and shrug shoulders Assess upper cerebellar o Rapid alternating movements o Finger to nose Assess lower cerebellar o Heel to shin test- rub along shin Inspect chest for symmetry o Even and symmetrical Inspect chest/lung expansion symmetry o T10- respiratory expansion o Look for CVA tenderness Asses skin integrity o temp, color, turgor, scars Strength and ROM                      o Pedal push/pull o Grip push/pull Reflexes- +2 is normal o 1 upper- Biceps, Brachioradialis, Triceps o 1 lower- patellar Capillary refillo Less than 3 seconds o Test the fingers, test the toes (verbal) Aortic valve- 2nd ICS right Pulmonic valve- 2nd ICS left Erb’s point- 3rd ICS Tricuspid valve- 4th ICS Mitral valve- 5th ICS Auscultate apical heart rate with the patient leaning forward o Would count for a full minute Verbalize respiratory effort o Pattern/rhythm o Respiratory expansion o Tactile fremitus- say 99 Posterior breath sounds- 8 places Lateral breath sounds Anterior breath sounds- 6 places Urine/ stool o color, consistency, burning, urgency, frequency Inspect abdomen Auscultate all 4 quadrants o Arteries for bruits o Start in RLQ Percuss all 4 quadrants Palpate all 4 quadrants Lower extremities- Strength and ROM Asses skin integrity o temp, color, turgor, scars Reflexes o Patellar Pulses o Popliteal, dorsalis pedis o Capillary refill