TABBA HEART INSTITUTE

Nursing Educational Services

HEALTH ASSESSMENT PHYSICAL EXAMINATION DOCUMENTATION SHEET
1

MENTAL STATUS

SKIN

HEAD

FACE
EYES

EARS

NOSE

Texture/Temp
Pigmentation
Local Lesion
Hair/ Nails

Lids
Conjunctiva
Cornea
Sclera
Pupils
EOM (CN III,IV,&VI)
Lens
Gross vision
Fundoscopic
examination
Pinnae
Hearing
Weber
Rinne
E.Canais
Tympanic Membrane
Septum
Sinuses
Turbinate

MOUTH
Lips
Teeth
Gum
Tongue

NECK

NODES

Buccal mucosa
Pharynx
Tonsils /Pillars
Trachea
Thyroid
Mobility
Pre Pot auricular
Occipital,tonsillar
Submaxilllary

20 years old male/female ,alert awake and oriented *3 .Is well built ,Tall muscular , wear glasses,
smiling and friendly ,does not seems to be in distress, Memory intact, speech coherent& fluent.
Moist, Wheatish, warm skin
No Hypo/hyper pigmentation
No lesions/ small pink circular papule at fore arm
Hair ,Black Short, clean nails ,pink capillary refill brisk
Head and skull contour properties, no tenderness, scalp clean, no dandruff.
CN VII ( facial nerve ) Facies symmetrical, facial movement (smiling frowning) CN5 (Trigerminal
nerve), Jaw clench ,light touch on 3 face areas
Symmetrical, no ptosis, edema and lesions
Pink, no redness and lesions. Palpate lacrimal gland & sac
Clear, Transparent, no opacity or shadows
Clear pale white, no abnormalities seen Iris round intact
Equal, round, reactive to light and accommodation PERRLA
Symmetrical in 6 directions( H ), no nystagmus, converges normally
Clear distinct Margin , Red reflex Visible
Visual fields full by confrontation ACUITY : R 6/6 L 6/6 Corrected Peripheral vision by 12 places
Orangish retina ,no hemorrhages
Disc creamish pale ,sharp margins, no edema
Positioned with lateral Canthus of eye, no tenderness at mastoid ,tragus ,No cyst and lesion
Intact, Able to hear whispered voice
CN vll,(Acoustic ) no lateralization ve test------- normal
AC> BC +ve Rt ear lateralization
Patent no lesions , slight brownish wax is present
Pearly grey , Intact , no lesion or perforation Cone of light seen
Observe for nasal patency
Skeleton intact ,no deformity ,septum midline CN l ( Olfactory nerve)
No tender
Pink , non edematous
CN Xll ( Hypoglossal) tongue movement
Moist pink no cracking
28 white no caries , No mal occlusion
Pink ,moist, no bleeding
Mobile,mid line, pink ,rough, papillae seen , ventral surface moist ,frunulum,ducts, CN lx (Gloss
pharyngeal gag reflex , uvula rise ,say Ah
Pink moist ,no ulcers ,lesions
Pink moist, no lesions, no exudates , uvula rise symmetrically
Absent
Midline
Non palpable, no enlargement seen
Full ROM of neck , no discomfort / tenderness
CN ll shoulder shrug
Bilaterally all nodes non palpable ,non tender

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BREASTS

11

HEART

12

LUNGS /THORAX

13

ABDOMEN

14

PERIPHERIES

15

MUSCULO
SKELETAL

Symmetry
Nipples
Masses
Precodium
PMI
AUSCULTATION
JVP
Configuration
Breathing
Expansion / Fermitus
Excursion
Percussion
Auscultation
Appearance
Bowel sounds
Bruits
Percussion
Palpation
Tenderness
Masses & Hernia
Carotids .R L
Radials RL
BrachialsRL
Femorals RL
Popliteal RL
DPs RL
PTs RL
Gait
Spine
Pelvis
Extremities
Muscle strength
ROM

16

17

NEURAL NERVES
CRANIAL NERVES

REFLEXSES:

Cerebellar
Sensory( touch)
Romberg ,Position
Vibration
Knee RL
Ankles RL
Biceps RL
Triceps RL
Babinskis sign RL
Gait/posture
Muscle strength/grip

Small / moderate , symmetrical on 4 positions

Erect ,directed to center , no discharge seen. Axillary nodes non palpable
No lumps or masses felt. No Dimpling, flattening
No heaves, lifts or thrills seen
Palpable at 5th LICS 5 cm away from sternum or at MCL
S1,S2 audible, no murmurs , gallop heard
Not raised @ 30 angle
Symmetrical ,AP: Lateral = 1:2, no thoracic abnormality
Easy ,quiet breathing ,18/ m , no use of accessory muscle
Symmetrical ,Fermitus more on Apex than bases
Diaphragmatic excursion 4 cms (R+L)
Resonant all over ,except scapula
Vesicular breathing all over lung fields , no adventitious sounds
Flat ,no striae,/ Pulsation visible , umbilicus in center
Active in RLQ
No aortic, Renal , iliac bruits
Tympany all over, liver dullness, liver span 6-12 cm @ MCL
Abdomen soft ,Kidneys , liver, not palpable
Non tenderv, no CVA tenderness, rebound tender ness.
No masses and Hernia

All pulses palpable 2 + bilateral

Strength of Upper / lower Extremities, Grip

Stable erect gait ,walk smoothly , walk heel to toe
Spinal curves WNL, no deformity, on tender vertebral column
Hopping
No tenderness, no tilt
No edema, redness
Muscle strength
Full ROM of all upper & lower joints. No pain no limitations
All cranial nerves ( olfactory , optic , oculomotor,trochlear,trigerminal, abducen, facial, auditory,
glossopharyngeal, vagus, spinalaccessory, hypoglossal) intact
Balance ,Coordination, point point testing intact
Sense of light touch ,pain temperature intact
Romberg negative ,position sense intact
Intact
+2

+2

+2 +2

Negative
Steady erect posture
Strong grip bilaterally, muscle tone WNL and strength +5

+2
+2

+2
+2

+2
+2 +2