Documenting physical assessment findings

1. PREPARED BY:
USHA RANI KANDULA,
ASSISTANT PROFESSOR,
DEPARTMENT OF ADULT HEALTH NURSING,
ARSI UNIVERSITY, ASELLA, ETHIOPIA,
EAST AFRICA.

2.  Therefore, this examination and charting entry
are more extensive than what would be
expected of a staff nurse.

3.  Keep in mind that you should use only
abbreviations on your clinical agency’s approved
list.

4.  General Survey 56-year-old obese man presents
to the clinic for a physical exam in no apparent
distress.

5.  Pt appears stated age; is well dressed and
groomed; and alert and oriented to time, place,
and person.

6.  Speech is clear, response and affect appropriate.
 Moves all extremities well, gait steady and
balanced.
 Smells of cigarettes.

7.  Height 5 ft 4 in.
 Weight 185 lb (84 kg)
 BP 166/100
 Pulse 88 beats/min
 RR 22 breaths/min
 Temp 98.5°F (36.9°C), oral
 BMI 33

8.  Integumentary Skin even in color, warm & dry,
good turgor, no suspicious lesions.
 Well healed scar in right inguinal area.

9.  Hair clean, coarse, evenly distributed. Some
graying.
 Nails pink, brisk capillary refill, no clubbing.

10.  Head & Neck Normocephalic, erect, midline.
Scalp mobile, no lesions, tenderness, or masses.
Facial features symmetrical.

11.  Thyroid gland symmetrical and not enlarged;
cervical lymph nodes not palpable or tender.

12.  Eyes Snellen = right eye 20/100, left eye 20/100,
both eyes 20/100. Color vision intact. Difficulty
noted with near vision.

13.  Visual fields normal by confrontation.
 Extraocular movements intact.

14.  PERRLA at 3 mm by direct and consensual.
 Eyes clear and bright, + blink, no lid lag or
abnormalities.

15.  Anterior chamber clear.
 Cornea & iris intact. Sclera white, conjunctiva
clear.

16.  Lacrimal glands and ducts nontender.
 + red reflex bilateral, discs flat with sharp
margins, vessels intact, retina & macula even in
color.

17.  Ears, Nose, & Throat Skin intact, no masses,
lesions, or discharge.
 Position WNL.
 External ears nontender to palpation.
 + whisper test.

18.  Weber—no lateralization.
 External canals clear without redness, swelling,
lesions, or discharge.
 Tympanic membranes intact, light reflex and
bony landmarks visible; frontal and maxillary
sinuses nontender.

19.  Nares patent, able to distinguish familiar odors,
mucosa pink, no discharge, septum intact with
no deviation.
 Mouth Lips, oral mucosa, gingivae pink with no
lesions.

20.  All teeth present and in good repair.
 Pharynx pink, tonsils absent, palate intact.
 Symmetrical rise of the uvula, + gag and swallow
reflex.

21.  Tongue smooth, pink, symmetrical, mobile,
without lesions, taste intact (correctly identified
sweet, salty, and sour).

22.  Respiratory Respirations 22 breaths/min and
unlabored.
 Trachea midline, AP < transverse chest diameter.

23.  Chest expansion symmetrical.
 No tenderness, scars, masses, or lesions.
 Diaphragmatic excursion 5 cm. Lungs clear to
auscultation.

24.  Cardiovascular PMI @ MCL at 5th ICS, P 85,
regular, no murmurs, gallops, or thrills present;
pulses +2, no bruits or thrills, no varicosities;
jugular venous pulsation 2 cm at 45°.
 Carotids without bruits.

25.  Breasts Symmetrical.
 No masses, lymphadenopathy, or discharge.

26.  Abdomen Abdomen soft, rounded, no masses or
pulsations.
 Surgical scar R inguinal area. + bowel sounds, +
tympany throughout.

27.  Musculoskeletal Normal spinal curvature. Joints
and muscles symmetrical, no deformity. +
Bilateral knee pain (right more than left).

28.  Full ROM in upper and lower extremities, + 5
muscle strength, moderate crepitus
 right knee.

29.  Neurological Awake, alert, and oriented to time,
place, and person.
 CN I–XII intact.

30.  Gait steady and coordinated; negative Romberg;
unable to do deep knee bends due to pain.
 Point-point localization, superficial and deep
sensation intact, + 2 deep tendon reflexes.

31.  Genitourinary Circumcised male; penis
nontender, no masses, urethral meatus midline,
no discharge;

32.  testicles descended bilaterally, nontender,
inguinal and femoral canals free of masses,
prostate small, smooth, mobile, nontender.
 Rectal wall smooth, no masses, stool
 hemoccult negative.