PHYSICAL ASSESSMENT CHECKLIST
General Survey
______ Weight: ______ BMI: _________
Body Built: Proportionate Excessively thin Obese
Ectomorph Mesomorph Endomorph
Relaxed w/ erect posture
Coordinated Movements
Uncoordinated movements Tremors
Clean and neat Dirty and unkempt
No body odor Foul body odor
Breath Odor: No breath odor Foul breath odor
No signs of distress Signs of distress present
_ bending over _labored breathing
_ Others: Specify: ______________
Healthy appearance pallor weakness
Cooperative Negative or inappropriate to situation
Appropriate to the situation
Inappropriate to the situation
Understandable or moderate pace
Rapid or slow pace
Exhibits thought association
Lacks association, exhibits confabulation
Logical sequence, makes sense and has the sense of reality
Illogical sequence, flight of ideas and has confusion
Color: light brown fair complexion deep brown
Pallor cyanosis jaundice erythema
no edema has edema where: _________
freckles birthmarks where: _________
Nevi: _flat _raised abrasions lesions
moisture in skin folds and axillae
Excessive moisture excessive dryness
uniform within the normal range
Hyperthermia: _ Generalized _ Localized: where? _________
Hypothermia: _ Generalized _ Localized: where? _________
springs back to previous state when pinched
Moves back slowly when pinched
Nails
convex spoon nail clubbing
highly vascular and pink pallor bluish
smooth texture excessively thick excessively thin
presence of grooves or furrows
intact epidermis hangnails paronychia (inflame)
Blanch test: prompt return delayed return
Skull
normocephalic lack of symmetry
smooth, uniform consistencies, absence of nodules/masses
Sebaceous cysts or local deformities
white color other color due to depressions
Tenderness: no tenderness with tenderness
Hair
even distribution patches of hair loss
thick thin
silky, resilient hair brittle oily dry
no infections or infestations
Flakes sores lice ring worms
Face
Features and symmetry: symmetric features asymmetric features
Eyes
hair evenly distributed loss/unevenly distributed
asymmetrically aligned
equal movement unequal movement
curled slightly outward curled inward
skin intact, no discharge, bilateral blinking, close symmetrically
redness, swelling, closes asymmetrically, infrequent blinking
transparent with some evident capillaries
Jaundice sclera excessively pale lesions/nodules
shiny, smooth, and pink red in color
extremely pail extremely red lesions/nodules
Sclera: white and clear jaundice w/ lesions redness
transparent, smooth, shiny and the details of iris are visible
cloudy or opaque, surface not smooth
no shadows of light in iris, depth are about 3 mm
crescent shape shadows on far side of the iris, shadow clambers
blinks when the cornea is touched, trigeminal nerve intact
one or both eyelids fail to respond
brown/dark brown in color, oval and flat
Bulging of iris toward cornea
black in color, equal in size cloudiness
Both illuminated and nonilluminated contricts
Neither pupil constricts
was able to read newsprint wasn’t able to read newsprint
Left: _______ Right: ________ Both: ________
no edema or tearing presence of edema and tearing
coordinated movements uncoordinated movements
Visual fields: was able to see in the periphery wasn’t able to see
Ears
same as the facial color bluish pallor
Aligned w/ the outer canthus low-set ears
Firm, recoils when folded tendered when moved, flaky
Acuity test:
audible not audible
able to hear in both ears unable to hear in one or both ears
positive (heard in both ears) negative
positive (AC > BC) negative (BC > AC or BC = AC)
Nose
symmetric asymmetric
No flaring with flaring
clear, watery discharge abnormal discharge
Mucosa is pink mucosa is red
No lesions presence of lesions
intact and in midline deviated to the right or to the left
air moves freely air movement is restricted
no tenderness with tenderness
no tenderness with tenderness
Mouth
pinkish pallor bluish
symmetrical asymmetrical
able to purse lips wasn’t able to purse lips
uniform pink color not uniform – redness in color
How many? _________
smooth and intact dentures irritated area under dentures
smooth, shiny enamel brown/black enamel
pink gums red gums
no retraction of gums bleeding gums
smooth tongue base w/ prominent veins swelling/ulcerations
central position deviated from the center
moves freely, no tenderness restricted mobility w/ tenderness
no palpable nodules swelling w/ nodules
light pink in color discoloration of the palates
regular texture irritations
positioned in midline of soft palate deviated to one side
pink and smooth posterior wall reddened/ edematous
pink and smooth inflamed
no discharge presence of discharge
normal sized swollen
Neck
no tenderness with tenderness
central placement deviated to one side
Thyroid gland: not visible during inspection visible diffusion or local enlargement
Thorax
1:2 ratio barrel chest
Chest symmetric chest asymmetric
Spine vertically aligned exaggerated spinal curvature
_Kyphosis _ lordosis _ scoliosis
uniform temperature hyperthermia
no tenderness with tenderness
no masses lumps, depressions or bulges present
symmetric chest expansion asymmetric chest expansion
bilateral symmetry of the vocal fremitus decreased/absent
percussion notes resonate asymmetry in percussion
vesicular and bronchovesicular breath sounds adventitious sounds
1:2 ratio barrel chest
Chest symmetric chest asymmetric
Spine vertically aligned exaggerated spinal curvature
_Kyphosis _ lordosis _ scoliosis
uniform temperature hyperthermia
no tenderness with tenderness
no masses lumps, depressions or bulges present
symmetric chest expansion asymmetric chest expansion
bilateral symmetry of the vocal fremitus decreased/absent
percussion notes resonate asymmetry in percussion
vesicular and bronchovesicular breath sounds adventitious sounds
Cardiovascular
Aortic area: no pulsations with pulsations
Pulmonic area: no pulsations with pulsations
no pulsations with pulsations
No lifts or heaves diffuse lifts or heaves
pulsation visible in PMI PMI displaced laterally or lower
No lifts or heaves diffuse lifts or heaves
S1 and S2: heard at all sites varying intensity w/ different beats
symmetric pulse volumes asymmetric volumes
Full pulsation, thrusting quality decreased pulsation
No sound heard during auscultation presence of bruit in arteries
veins not visible veins visibly distented
Breast
Size & symmetry
round, slightly unequal in size, generally symmetric
recent change in breast size, swellings, marked asymmetry
breast even with chest wall, if obese may be similar in shape w/ women
recent change in breast size, swellings, marked asymmetry
uniform in color localized discoloration/hyperpigmentation
with striae without striae
no swelling or edema with swelling or edema
no tenderness with tenderness
round oval
light pink dark brown
bilaterally the same not bilaterally the same
round everted point in the same direction
no discharge presence of discharge
no tenderness with tenderness
Axillae no tenderness with tenderness
Abdomen
unblemished skin rashes or other lesions
Uniform color tense or glistening skin
Silver-white striae purple striae
flat, rounded distended
No evidence of enlargement of the liver or spleen
Enlargement of the liver or the spleen
Symmetric countour asymmetric contour
symmetric movements asymmetric movements
no visible vascular pattern visible venous pattern
audible absent
loud bruits absent
bruits over renal or iliac arteries absent
tymphanic over the stomach and gas-filled bowels
Large dull areas
No tenderness,relaxed with tenderness
tenderness in the xiphoid pocess, cecum and sigmoid colon
Generalized/localized areas of tenderness, mobile of fixed masses
equal in both sides atrophy hypertrophy
no contractures malposition of body parts
no fasciculation/tremors presence of fasciculation/tremors
normally firm atonic
