Assessment Flashcards
Eyes
Blurred vision, glasses, contacts, photophobia, excessive tearing, night blindness, diplopia, drainage, pain, blind spots, flashing lights, halos, glaucoma or cataracts.
Ears
Hearing deficits, hearing aid, discharge, vertigo, tinnitus, earaches, infection.
Musculoskeletal
Muscle pain, joint stiffness, cramps, back pain, limited movement in affected area, redness swelling, weakness, bony deformity, broken bones, dislocations, sprains, gout, arthritis, osteoporosis, herniated disc.
Cortical Sensation/Neuro
- Stereognosis (familiar object placed in hand)
- Graphesthesia (number or letter drawn in hand)
- Two-point discrimination (at what point can two points no longer be felt)
Throat/Neck
Hoarseness, change in voice, frequent sore throat dysphagia, pain/stiffness, nodularities, goiter, lymphadenopathy.
Female Reproductive
Discharge, change in libido, sterility, pain during intercourse, menses, LMP, start of menarche, regularity, duration, amount of bleeding, premenstrual symptoms, menopause/age of onset/duration/bleeding.
Obstetrical: number of pregnancies, births, types of delivery, complications, birth control
Mental Status /Neuro
Assess Orientation
• Identifies self, place and date (A&O x 3)
Assess Memory
• Immediate: Give the patient three things to remember (example: cat, cloud, ball). Asks the patient to repeat them to the examiner at a later point during the examination.
• Recent: What did you have for breakfast?
• Remote: Where were you born?
Assess abstract reasoning
• Have the patient explain the meaning of a parable “If I say its raining cats and dogs, what does that mean?”
Assess judgment
• Provide the patient with a hypothetical situation and ask: “What they would do if your house was on fire?”
Assess general knowledge
• Who is the president?
Assess Attention
• Serial calculations: subtract by 2s from 20
Neck Assessment
Inspect for masses or deformity
Inspect trachea for position
Assess neck ROM (active followed by resistance)
Palpate the thyroid gland
Assess Cranial Nerve XI (Spinal Accessory)
• ROM head against resistance
• Shrug shoulders against resistance
Assess lymph nodes (naming each of the chains correctly)
Hips
- Inspect hips for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM of the hips (abduction/adduction, flexion/extension, internal/external rotation)
- Assess strength of hips (abduct/adduct)
Adams Test - unlevel hips
Ear Assessment
Inspect the ears for size, alignment, configuration, skin color, lesions, and discharge.
Palpate the external ear, bilaterally
Inspect the auditory canal
Perform otoscopic exam describing structures visualized
Assess Cranial Nerve VIII (Vestibulocochlear/Acoustic)
• Whispered voice test at 1-2 feet on non-occluded ear
• Weber & Rinne Test
Assessment of Head
Inspect head for size, contour, obvious deformities
Inspect hair for distribution, color, condition
Inspect hair for infestations
Palpate head for depressions, masses, pain
Palpate hair for texture
Psychological
Irritability, nervousness, tension, stress, increased stress, suicidal/homicidal thoughts, anxiety or sleep disturbances, difficulty in concentrating, mood changes or depression.
PVD
Inspect the upper extremities
• Temperature, color, & hair distribution
• Condition of skin and presence of edema, ulcers, capillary refill
Inspect the lower extremities
• Temperature, color, & hair distribution
• Condition of skin and presence of edema, ulcers, capillary refill
Palpate upper extremity pulses
• External brachial and radial
Palpate lower extremity pulses
• Femoral, popliteal, dorsalis pedis, posterior tibial
Demonstrate how to assess the Ankle Brachial Index and calculate the value (one side)
• Verbalize normal and abnormal scores and if this patient is normal
Pulmonary
Inspect thorax for symmetry, posture, and deformity
Inspect thorax for AP – Transverse diameter
• Verbalize what they should be and if today’s findings are normal
-Palpate intercostal spaces for tenderness & pain (anterior) (minimum of 6 ICS)
-Palpate intercostal spaces for tenderness & pain (posterior and lateral) (minimum of 6 ICS posteriorly and 4 ICS laterally)
Palpate costal angle
• verbalize if finding is normal
-Palpate tactile fremitus (anterior and posterior)
-Assess and report thoracic expansion (posterior)
Percuss anterior and posterior thorax
• At least 6 areas each
Auscultate anterior and posterior thorax
• At least 6 areas each
Assess and demonstrate diaphragmatic excursion (posterior)
• Verbalize findings
Demonstrate one technique: bronchophony (99-scope)
Coordination/Neuro
- Upper extremities (finger-thumb/ pronate-supinate)
- Lower extremities (toe tap/heel-shin)
- Assess Romberg (protects patient safety) close eyes place hands on each side and have patient stand there.
Cardiovascular
Inspect the Precordium (Aortic, Pulmonic Tricuspid, & Mitral)
• Pulsations, lifts, heaves
Palpate the Precordium (A,P,T,M)
• Pulsations, thrills
Auscultate the Precordium (A,P,T,M)with patient sitting upright: Diaphragm
• Repeat with bell
Auscultate the Precordium (A,P,T,M)with patient supine: Diaphragm
• Repeat with bell
Auscultate the Precordium (A,P,T,M) with patient in left lateral position: Diaphragm
• Repeat with the bell
Report the location and quality S1, S2
- Compare the apical pulse via auscultation with the radial pulse via palpation
Report presence or absence of: Murmurs, rubs, arrhythmia, gallop, clicks
Auscultate the carotid arteries
• Then palpate the carotid arteries (one at a time)
Chief Complaint
O- onset L- location D-duration C- character A- associated/aggravating R- reliving T- timing S- severity
Male Reproductive
Change in Libido, infertility, sterility, impotence, pain during intercourse, onset puberty, testicular pain, penile discharge, erections, hernias, enlarged prostate, urine stream.
General
Fever, Chills, change in energy, night sweats, weight changes
Focused Health History
Biographical Data Chief Complaint History of Present Illness Past Medical History Family History Social History Select Review of Systems
Neurological
Headaches, change in coordination, loss of movement, tics or tremors, change in smell, taste, or speech, forgetfulness, tremors, seizures or loss of consciousness, involuntary movements, weakness, head injury, vertigo, balance, or syncopal episodes.
Accuracy of Movement/Neuro
- Finger-to-nose
* Finger-to- practitioner’s finger
Biographical
Name, occupation, marital status, children
Nose Assessment
Inspect skin surface, contour, relationship of nares to each other, and presence of discharge.
Inspect the internal structures of the nose.
Palpate the external nose
Test the patency of the nares
Assess Cranial Nerve I (Olfactory)
Able to identify an odor
Skin
Rashes, itching, dry or moist skin, changes in skin pigmentation or texture ecchymoses, change in color or size of moles, any changes in hair distribution.
Headache
S- Head injury, coordination, loss of movt, visual disturbances, change in smell/taste, ringing in the ears, dizziness, vertigo, tremors, loss of sensation to any part of body, tingling or numbness, loss of balance, involuntary movt’s. Diet, Menses, stress triggers.
PMH, FH, Social Hx, General, Lungs, Cardiac, Neuro
Cardiac- (Listen with Bell/Diaphragm verbalize)
Lung - Inspect (im watching you breath WNL, (ascultate 6/6/4).
Eyes - internal inspection for edema/bleeding
CN2 for vision, 3,4,6 occular motor movt.
Neuro - Gait, Numbness or tingling, CN 5 Trigeminal (touch face), 7 - Facial (raise eyebrows, puff out cheeks, smile).
GI
Change in appetite, N/V/D or constipation, normal/abnormal bowel habits, melena, rectal pain, hematemesis, change is stool color or consistency, belching or flatulence, regurgitation, heartburn or dysphagia, abdominal pain, peptic ulcers, gallstones, or GERD, jaundice, hepatitis, ulcerative colitis, diverticulitis, or Crohn’s disease.
Deep Tendon/Clonus
• Biceps - bend arm, limp tap • Brachioradialis- indirect in AC • Triceps- tap forearm • Patellar- knee • Achilles • Demonstrate how you would assess for Clonus Assess Superficial Reflexes • Abdominal reflexes • Plantar response
Hands/Fingers
- Inspect hands for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM of digits (fist/ fan)
- Assess strength of hands (hand grasp)
Proprioceptive/Neuro
- Assess ability to identify up/down position: toes/ fingers
* Assess vibration sense using tuning fork toes/ fingers
Past Medical Hx
Chronic Medical Prob. Hospitilization/Surgeries/Injuries Medication List OTC/Herbal/Birth Cnt/Vitam Immunizations/Flu/PNA Allergies - Seasonal/Medicinal Mental Health Female - LMP
Wrist
- Inspect wrists for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM of wrists (flexion/extension and ulnar/radial deviation)
- Assess strength of wrists (flexion/extension)
- Perform Phalen and Tinel Testing
Urinary
Change in color or frequency, dysuria, hesitancy, urgency, frequency, nocturia, polyuria, dribbling, loss in force of stream, bedwetting, change in urine volume, incontinence, suprapubic pain, kidney stones or UTIs, flank pain.
Mouth Assessment
Inspect lips, buccal mucosa, gums, and presence of saliva
Inspect floor of mouth and breath odor
Inspect number and repair of teeth; presence of implants, bridges, and dentures
Inspect tongue
If abnormalities noted, palpate tongue
Assess Cranial Nerve XII (Hypoglossal)
• Tongue movement
Inspect hard and soft palate
Inspect the tonsils and posterior pharynx
Assess Cranial Nerve X (Vagus) and CN IX (motor) (Glossopharyngeal).
• Say “Ah”/ Swallow water
Assessment of Face
Inspect face for symmetry with rest, movement, expression
Inspect face for color, condition of skin, scars or lesions
Palpate frontal & maxillary sinuses
Palpate temporal-mandibular joint for crepitation
Assess Cranial Nerve V (Trigeminal)
Motor: Symmetry of face/TMJ strength
Sensory: Light touch (face)
Assess Cranial Nerve VII (Facial)
Motor: Raise eyebrows; smile/frown; show teeth, puff cheeks
Sensory: Taste: sweet/salty
Knees
- Inspect knees for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM of both knees (flexion/extension)
- Assess strength of knees (flexion/extension)
• Performs Anterior drawer test
Assessing stability of Cruciate Ligaments
ACL – Draw tibia forward, forcing tibia to slide forward of the femur Positive – movement greater that 5mm
- Performs Posterior drawer test - Move tibia backward, forcing femur to slide forward of the tibia
- Performs Lachman test - twist motion - stability of ACL
• Performs McMurray test- Assess Medial and Lateral Meniscus
Medial - Supine hip/knee 90d, leg supported by examiner
Heel in one hand/hand on knee, fingers on joint space, externally rotate lower limb and push on lateral side of knee ( causing stress on medial side) while slowly extending leg
Positive – Palpable/audible click, pain, or grinding, lack of ability to extend leg
Lateral – Same hand placement – internally rotate lower limb and push on medial side of knee (varus stress on lateral side) slowly extending leg
Positive – Palpable/audible click, pain, or grinding.
Abdomen/Kidney
Inspect the abdomen
• Symmetry, contour, respiratory movement
• Pulsations, engorged veins or visible peristalsis
• Umbilicus, striae/scars, and hair pattern
Auscultate the abdomen for the presence of bowel sounds in 4 areas
Auscultate the abdomen for vascular sounds in three areas
• Aorta, renal arteries, iliac arteries
Auscultate the abdomen for a friction rub
• Over liver and spleen
Percuss the abdomen in all four quadrants
Assess span of the liver using one of the following (state which one while performing)
• Scratch test OR Hook Technique OR Percussion
Using light palpation assess all four quadrants.
Deeply palpate for pain and organ identification and size
• liver, spleen, and bladder
Assess costovertebral angle (CVA) tenderness using indirect percussion
-Perform Murphy’s Sign while verbally providing the rationale for exam
-Perform Iliopsoas muscle test while verbally providing the rationale for exam
-Perform Obturator Muscle test while verbally providing the rationale for exam
-Perform Rovsing’s sign while verbally providing the rationale for exam
-Perform Kehr’s sign while verbally providing the rationale for exam
Ankles/Feet/Toes
- Inspect ankles for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM (flexion/extension and eversion/inversion)
- Assess ankle strength (flexion/extension)
- Inspect feet/toes for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess ROM (curl, straighten, fan)
Social History
Diet - typical diet
Excersise
Sexual practices/birth control
Drug/Alcohol
Breast
Pain, tenderness, discharge, lumps, change in size, dimpling, rash, benign breast disease, breast cancer
Family Hx
DM, HTN, CA
Focused to CC
Muscles Relax/Contract/Symmetry
• Evaluate muscle mass relaxed and contracted state
Upper body
Lower body
Limb symmetry (comparison of measurement on both lower extremities via limb length or calf circumference)
Shoulder
• Inspect for erythema, deformity & symmetry
• Palpate for heat, tenderness, edema, and crepitation
• Assess active ROM of shoulders (abduction/adduction, flexion/extension, internal/external rotation and circumduction)
• Assess strength of shoulders (abduct/adduct)
• Advanced Shoulder examination
Performs drop arm test with explanation
Performs Neer’s Impingement test with explanation
ALL Muscular STRUCTURES
- Inspect – deformities, erythema, edema
- Palpate- Heat/tenderness, and crepitus with ROM
- ROM (see below for each assessment)
- Strength – 0-5 (active/no fatigue) full resistance
Cervical Spine – Active/Passive, Extension/Flexion, Lateral mvt., Rotation (apply resistance)
Back – Active/Passive, Flexion/Hyperextension, Lateral Bending, Rotation (strength Gravity)
Shoulder – Active/Passive, Flexion/Extension, Adduction/Abduction, Internal/External Rotation
(strength take arms out (deltoids) and have them push in and out)
Elbow – Active/Passive, Flexion/Extension, Supination/Pronation
Wrist – Active/Passive, Flexion/Extension, Ulnar/Radial Deviation, Rotation
Fingers- Active/Passive, Flexion/Extension, Fan, Thumb opposition, Finger grasp for strength.
Hip – Active/Passive, Flexion/Extension, Abduction/Adduction, External/Internal Rotation
Knee – Active/Passive, Flexion/Extension
Ankle – Active/Passive, Dorsiflexion/Plantar flexion, Inversion/Eversion, provide resistance
Toes – Active/Passive, Flexion/Extension, provide resistance
Shoulder
ROS
Cardiac – Inspecting/auscultating one position with diaphragm/bell
Lungs – Inspect/I am watching you breathe, WNL and auscultation
Meds how much and when is the last time.
Know what the physical activity in social activity is – always ask what they do for a living, makes a difference, how does it affect the day to day. Ask a little neuro so does it come from the spine like numbness and tingling.
Physical exam – gait, posture, ROM bilaterally, active and passive. Inspect for any deformities. Crepitus? Compare bilaterally. Arm drop test, nears impingement test. Deep tendon reflex for triceps/bicep. ROM in the elbow, inspect. Peripheral pulses in the arms radial/brachialis. Shoulder strength. Muscle mass in relaxed and contracted state.
Nose / Sinuses
Frequent colds, discharge, itching, hay fever, postnasal drip, stuffiness, sinus pain, polyps, sinusitis, obstruction, epistaxis, change in smell, allergies
Verbal Report
Subjective
Objective
Assessment
Plan
Cardiovascular
Nocturnal Dyspnea, cyanosis of the lips, or extremities, chest pain, palpitations, heart murmur, syncopal episodes, orthopnea, edema, cold hands.feet, leg cramps, HTN, valvular disease, MI, DVT, Anemia, varicose veins, or thrombophlebitis
Exteroceptive sensation/Neuro
- Assess light touch in upper and lower extremities (moves distal to proximal)
- Assess ability to differentiate sharp-dull in upper and lower extremities (moves distal to proximal)
Respiratory
Dyspnea, shortness of breath, SOB with exertion, sputum, cough, sneezing, wheezing, hemoptysis, frequent URIs, pneumonia, emphysema, asthma, tuberculosis, Covid19.
General MS/Neuro
Gait
• Ease of movement, arm swing, symmetry of movement, stance, steadiness
• Tandem walk: towards examiner and away from examiner
Posture
• Alignment of scapula, iliac crest, knees
• Inspect for scoliosis, lordosis, kyphosis
- Include Adam’s test (bend over and look at spine)
Back
Inspect and palpate for deformities, abrasions, symmetry
Assess active ROM (flexion/extension, rotation, and lateral flexion)
Perform straight leg raise test
Mouth
Toothache, tooth abscess, dentures, dental habits, bleeding/swollen gums, difficulty chewing, sore tongue, change in taste, lesions, change in salivation, bad breath, caries, teeth extractions.
Elbow
- Inspect for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM of elbows (flexion/extension, supinate/pronate)
- Assess strength of elbows (flexion/extension)
- Perform assessment for medial and lateral epicondylitis
Eye Assessment
Inspect eyebrows and eye lashes; distribution and symmetry
Inspect the lids
Inspect and palpate the lacrimal apparatus
Inspect the sclera and conjunctiva
Inspect and assess the iris, pupil and cornea
Assess Cranial Nerve II (Optic) (Snellen, results verbalized
Assess Cranial Nerves III, IV, VI (extraocular eye movement)
Test peripheral visual fields using confrontation
Assess corneal light reflex and explains rationale
Perform cover-uncover test and explains rationale
Assess Pupils
• verbalize Pupils equal, round, reactive to light and accommodation)
Ophthalmologic exam
• verbalize optic cup, optic disc, macula and vessels
