PE Assessment

Question 1

Approach/manner with client

Answer 1

o Washes hands Can happen at same time
o Introduces self
o Ask 5 questions related to the client’s concern

OLDCART
Onset Location Duration Characteristics Aggravating Factors Relieving Factors Treatment (Pain Assessment Tool)

MSK or Neuro
<3 questions= 1pt

5 or more= 2pts

o Informs client of what to expect
o Provides appropriate draping
o Logical progression; few position changes

Progression/Position Changes: 1.5

Use of Foot Table: 1
o Minimal use of notes
o Timely completion
o Closing remarks

Question 2

Heart

**Students MUST verbalize valve name AND landmarks WHILE listening with stethoscope. Sitting or lying

Answer 2

o Inspect & palpate PMI Sitting or lying
o Auscultate precordium: 4 areas
(aortic, pulmonic, tricuspid, mitral) with bell and diaphragm
• Aortic (2nd RICS – just right of sternum)
• Pulmonic (2nd LICS – just left of sternum)
• Tricuspid (4th LICS – just left of sternum)
• Mitral/PMI (5th LICS – midclavicular line; apex)

Aortic w/verbalized landmarks =0.5pts
Pulmonic w/verbalized landmarks=0.5pts
Tricuspid w/verbalized landmarks=0.5pts
Mitral w/verbalized landmarks=0.5pts

Question 3

Heart

Answer 3

Sitting or lying

Aortic w/verbalized landmarks =0.5 pts
Pulmonic w/verbalized landmarks=0.5 pts
Tricuspid w/verbalized landmarks=0.5 pts
Mitral w/verbalized landmarks=0.5 pts

Question 4

Neck Vessels

Answer 4

o Inspect jugular veins Sitting 1
o Palpate carotid pulses bilaterally 1
o Auscultate carotid arteries using bell
(Instruct to hold breath)
1

Question 5

Peripheral vascular system

Answer 5

UPPER EXTREMITIES-Arms & Hands

LOWER EXTREMITIES- Legs AND Feet

Question 6

Upper extremities

o Inspect:

Answer 6

Color=0.2 pts
Lesions=0.2 pts
Edema=0.2 pts
Clubbing=0.2 pts
Muscle Size and Symmetry=0.2 pts

Question 7

Lower Extremities

o Inspect

Answer 7

Color=0.2 pts
Lesions=0.2 pts
Edema=0.2 pts
Clubbing=0.2 pts
Muscle Size and Symmetry=0.2 pts	1

Temperature=0.33 pts
Texture=0.33 pts
CRT (now or w/lungs)= 0.33 pts
Dorsalis Pedis=0.5pts
Posterior Tibial=0.5pts	2

Question 8

Thorax and Lungs

Inspect:

Auscultate:

Answer 8

Skin=0.2pts
Color=0.2pts
Lesions and/or Scars= 0.2pts
Shape & configuration=0.2pts
Effort of Breathing=0.2pts

Anterior: 3L/3R spots= 1pt
Posterior: 3L/3R spots= 1pt
Lateral: 1 spot L & R= 1pt

Question 9

Neuro Orientation

Answer 9

Orientation
o A&O x 4

<4= 0.5pts
4= 1pt

Question 10

Pupils

(PERRLA)

Have pt. remove glasses

Answer 10

Size= 0.2pts
Shape=0.2pts
Symmetry=0.2pts
Reactivity=0.2pts
Accommodation=0.2pts

o 6 Cardinal positions of gaze
Pt. can wear glasses

Question 11

Motor

Answer 11

o Ask patient to stick out tongue, and move side to side.
o Ask patient to frown and smile (show teeth)
o Ask patient to squeeze eyes shut

Question 12

Coordination do one

Answer 12

o Finger-to-nose or

o Finger-to-finger

Question 13

Sensory

Answer 13

Assess both upper & lower extremities 2 touches each limb

o Light/soft touch
o Sharp/hard touch

Question 14

Reflexes

Answer 14

o Quadriceps/Patellar reflex

.5

Question 15

o TMJ: Open/close & jaw jut

Answer 15

Palpate jaw

Question 16

o Cervical Spine: ROM rotate

Answer 16

Rotate = 0.25pts
Tilt = 0.25pts

Question 17

o Shoulders:

Answer 17

Behind head = 0.25pts

Behind back = 0.25pts

Question 18

o Elbows:

Answer 18

Flexion = 0.25pts
Extension = 0.25pts

Question 19

o Wrists:

Answer 19

Flexion = 0.33pts
Extension = 0.33pts
Supination = 0.33pts
*All three = 1pt

Question 20

o Hands/fingers:

Answer 20

(both hands)
Flexion=0.25pts
Extension=0.25pts
Grip=0.25pts
Palpate Joints=0.25pts

Question 21

o Hips:

Answer 21

Flexion=0.33pts
Abduction=0.33pts
Adduction=0.33pts
*All three = 1 pt

Question 22

o Knees:

Answer 22

Right Knee Flexion= 0.5pts

Right Knee Extension= 0.5pts

Question 23

o Ankles/feet:

Answer 23

(both feet)
Dorsiflexion= 0.25pts
Plantar Flexion=0.25pts
Inversion=0.25pts
Eversion=0.25pts

Question 24

o Spine (standing): Lumbar spine & hip flexion with support as needed

Answer 24

while standing

Question 25

o Gait: Observe walking across room

Answer 25

Walk across room

Question 26

Upper Extremities
o Palpate

Assess brachial and radial pulses

Answer 26

Temperature=0.2 pts
Texture=0.2 pts
Turgor=0.2 pts
CRT (now or w/lungs)= 0.2 pts
Edema=0.2 pts
Brachial Pulse=0.5pts
Radial Pulse=0.5pts

Question 27

Palpate abdomen

Answer 27

o Lightly in all 4 quadrants (knees bent) 4 quads w/o knees bent = 0.5pts
4 quads w/knees bent = 1pt

Question 28

Lower extremities

Palpatate

Answer 28

Temperature=0.33 pts
Texture=0.33 pts
CRT (now or w/lungs)= 0.33 pts
Dorsalis Pedis=0.5pts
Posterior Tibial=0.5pts	2