Adequate lightning

Facilities for handwashing.

Easy access to a restroom
A door or curtain that ensure privacy.
Adequate warmth for client comfort
A padded, adjustable table or bed
A lied receptacle for soiled articles
Sufficient room for moving to either side of
the client.
A client counter for placing examination
equipment.

SITTING used to take vital signs

SUPINE allows relaxation of abdominal muscles.
DORSAL RECUMBENT- used for patients having
difficulty maintaining supine position
SIMS assessment of rectum or vagina.
PRONE- assessment of hip joint and posterior
thorax.
LITHOTOMY-assessment of hip joint and posterior
thorax
KNEE-CHEST assessment of the rectal area; used
for brief period only
STANDING assessment of posture, gait & balance

Skin, Hair and Nails

Head and Neck
Eye, Ears, Nose, Mouth and Throat
Thorax and Lungs
Cardiovascular system
Peripheral vascular system
Abdomen, Breasts and Axillae
Urinary system
Male/Female Reproductive System
Muskuloskeletal System
Neurological System

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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Appears stated age

Level of consciousness
Skin color
Nutritional status
Posture and position comfortably erect
Obvious physical deformities
Mobility (gait, use of assistive devices, range of
motion of joints, no involuntary movement)
Facial expression
Mood and affect
Speech (articulation, pattern, content
appropriate, native language)
Hearing
Personal hygiene

1.
2.

Examine both hands and

inspect the nails.
For the rest of the
examination, examine skin
with corresponding regional
examination.

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2.
3.
4.

Radial Pulse
Respirations
Blood Pressure
Temperature (if indicated)

1.
2.
3.

4.

Inspect and palpate scalp, hair, and

cranium.
Inspect face (expression, symmetrycranial nerve VII).***
Palpate the temporal artery, then the
temporomandibular joint as the person
opens and closes the mouth.
Palpate the maxillary sinuses and the
frontal sinuses; if tender, transilluminate
the sinuses.

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2.
3.
4.
5.
6.

Test sensation in selected areas on face, arms,

hands, legs, and feet (superficial pain, light
touch, and vibration).
Test position sense (kinesthetic sensation) of
finger, one hand.
Test cerebellar function of the upper extremities
using finger-to-nose test or rapid-alternatingmovements test.
Test the cerebellar function of the lower
extremities by asking the person to run each
heel down the opposite shin.
Elicit deep tendon reflexes (biceps,
brachioradialis, patellar, and achilles).
Test the babinskis reflex.***

Recognize & React .

Cincinnati Pre-hospital Stroke Scale

1.

Facial Asymmetry

2.

Arm Drift

3.

Slurred Speech

(show teeth or smile)

(close eyes and hold both arms out)
(repeat you cant teach an old dog new tricks)

1.
2.

3.
4.
5.

5.

Test visual fields by confrontation (cranial

nerve II).
Test extraocular muscles (corneal light reflex,
six cardinal positions of gaze (cranial nerves
III, IV, VI).***
Inspect external eye structures.
Inspect conjunctivae, sclerae, corneas, irises.
Test pupil: size, response to light and
accommodation.
Darken Room
.
Using opthalmoscope, inspect ocular
fundus (red reflex, disc, vessels, and retinal
background).***

 Headache
Vomiting
Papilledema
6th nerve palsy

1.
2.
3.
4.
5.

Inspect the neck (symmetry, lumps, and

pulsations).
Palpate the cervical lymph nodes.
Inspect and palpate the carotid pulse, one
side at a time. If indicated, listen for
carotid bruits.
Palpate the trachea in midline.
Test ROM and muscle strength against your
resistance (head forward and back, head
turned to each side, and shoulder shrug
(cranial nerve XI)).
Step behind the person, taking your
stethoscope, ruler, and marking pen with
you.

Anterior Thorax (Angle of Louis, midsternal line,

midclavicular line, anterior axillary line, coastal
angle)
Posterior Thorax (vertebra prominens, midspinal
line, scapular line, posterior axillary line)
Lateral Thorax (midaxillary line)

1.
2.
3.
4.

1.

Inspect the posterior chest (configuration of

the thoracic cage, skin characteristics, and
symmetry of shoulders and muscles).***
Palpate (symmetric expansion; tactile
fremitus, lumps or tenderness).
Percuss over all lung fields.***
Percuss costovertebral angle,
noting tenderness.

Auscultate breath sounds;

note adventitious
sounds.***

1. Inspect (respirations and

skin characteristics).
2. Palpate (lumps, or any
tenderness).
3. Percuss the lung fields.
4. Auscultate breath sounds.

Tone

Quality

Normal
Location
Hyperresonance Booming
Childs
Lung
Resonance
Hollow Peripheral
Lung

Breath Sounds
-broncial-over trachea
-brochovesicular-1st &2nd ICS
at sternal
border ant.;post. At T4
medial to scapulae
-vesicular-peripheral lung
Adventitious Sounds
-crackles/rales/crepitations,
-wheezes/ronchi
-friction rubs

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2.
3.
4.
5.

6.
7.

Inspect the precordium for any pulsations and or

heave
Palpate the apical impulse and note the location.
Palpate precordium for any abnormal thrill.
Auscultate apical rate and rhythm.
Auscultate with the diaphragm of the
stethoscope to study heart sounds, inching from
the apex up to the base, or vice versa.***
Auscultate the heart sounds with the bell of the
stethoscope, again inching through all locations.
Turn the person over to left side while again
auscultating apex with the bell.

Jugular veins

Carotid arteries

1.

Inspect each side of neck for a jugular

venous pulse, turning the persons
head slightly to the other side.

JUGULAR VENOUS DISTENTION

Suprasternal
notch
Sternum
Manubriosternal
angle Angle of
Louis
Intercostal
Spaces

Valve

Area

Mitral

5th left ICS at the MCL

Tricuspid

Left sternal border, 4th left ICS

Pulmonic

Left sternal border, 2nd ICS

Aortic

Right sternal border, 2nd right ICS

Skin temp
Color
Pulses
Cap refill
edema

 Depress

pretibial area
& medial
malleolus for 5
seconds
Grade pitting
edema
1+ to 4+

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2.
3.
4.
5.
6.
7.
8.
9.

Inspect (contour, symmetry, skin

characteristics, umbilicus, and pulsations).
Auscultate bowel sounds.
Auscultate for vascular sounds over the
aorta and renal arteries.
Percuss all quadrants.***
Percuss height of the liver span in
midclavicular line.
Percuss the location of the spleen.
Palpate (light palpation in all quadrants,
then deep palpation in all quadrants).
Palpate for liver, spleen, kidneys, and aorta.
Test the abdominal reflexes, if indicated.

UTI
STD
Catheter
Frequency of Micturation
Color of urine
Abnormalities

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2.
3.
4.
5.

Note muscle strength as

person sits up.
Gait
Posture
Limbs
ROM

 Record

the data from the history and

physical examination as soon after the
event as possible.
It is important to remember that, from a
legal perspective, if it is not documented,
it was not done.
One way to keep your record complete
yet succinct is to study your writing style.
Avoid redundant introductory phrases.
A clear picture is worth many sentences
of words.