NECK VESSELS

1.

2.

3.

4.

1.

2.

3.

4.

Inspection:
Jugular Venous Pulse
___
Normally visible
___
Fully distended
Jugular Venous Pressure
___
Normally visible
___
Distended, bulging, or protruding
During expiration
During inspiration
Both
Auscultation:
Carotid arteries
___
(-) Blowing or swishing
___
(+) Bruit, blowing or swishing

___ Equally strong pulse

___ Pulse inequality

Palpation:
Pulse Amplitude Scale
___
0 = Absent
___
1+ = Weak
___
2+ = Normal
___
3+ = Increased
___
4+ = Bounding
HEART
Inspection
Apical pulse
___
Visible
___
Not visible
Palpation
Apical pulse
___
___

Palpable
Not palpable

Pulsations:
Apex
Left sternal border
Base
Auscultation
Heart rate
___
___
___

__ Yes
__ Yes
__ Yes __ No

__ No
__ No

Less than 60 beats per minutes (bradycardia)

60-100 beats per minute
More than 100 beats per minute (tachycardia)

5.

Rhythm

___
Regular
___
Irregular
Identical radial and apical pulse rates
Pulse rate deficit

6.
7.

S1: Loudest at the apex

S2: Loudest at the base

__ Yes
__ Yes

__ No
__ No

8. S3 (ventricular gallop)
__ Yes
__ No
9. S4 (atrial gallop)
__ Yes
__ No
10. Murmurs
__ Yes
__ No
If yes, specify characteristics:
Timing
During systole
During diastole
Intensity
Grade 1: Very faint, heard only after the listener has tuned in; may not be heard in all positions
Grade 2: Quiet but heard immediately on placing the stethoscope on the chest
Grade 3: Moderately loud
Grade 4: Loud
Grade 5: Very loud, may be heard with a stethoscope partly off the chest
Grade 6: May be heard with the stethoscope entirely off the chest
Pitch
High
Medium
Low pitch
Quality
Blowing
Rushing
Roaring
Rumbling
Harsh
Musical
Shape/Pattern
Crescendo (growing louder)
Decrescendo (growing softer)
Crescendodecrescendo (growing louder and then growing softer)
Plateau (staying the same throughout)
Location: _______________________________________
Transmission: ___________________________________
Ventilation/Position
During inspiration
During expiration
Change in body position: (What position?)
___ sitting position
___ lying position
___ standing position
Type of murmur (based on characteristics)
___ Midsystolic Murmurs
Innocent Murmur
Physiologic Murmur
Murmur of Pulmonic Stenosis
Murmur of Aortic Stenosis
Murmur of Hypertrophic Cardiomyopathy
___ Pansystolic Murmurs
Murmur of Mitral Regurgitation
Murmur of Tricuspid Regurgitation
Ventricular Septal Defect
___ Diastolic Murmurs
Aortic Regurgitation
Murmur of Mitral Stenosis
EYES AND EARS ASSESSMENT
Eyes:

1. Wears eyeglasses/contacts
__ Yes __ No
*If yes, what is the prescription grade: ________
2. Visual acuity of: ________
3. Symmetrical
__ Yes __ No
4. Discharge
__ Yes __ No
*If yes, what are the discharge characteristics: __________________
5. Swelling
__ Yes __ No
6. Redness
__ Yes __ No
7. Lesions/scaling
__ Yes __ No
*If yes, where: __________________
8. Eyebrows
Move symmetrically
__ Yes __ No
9. Eyelids/eyelashes
Eyelids meet together
__ Yes __ No
Eyelashes are evenly distributed
__ Yes __ No
Ptosis drooping of upper lid
__ Yes __ No
10. Eyeballs
Exophthalmos (protruding eyes)
__ Yes __ No
Enophthalmos (sunken eyes)
__ Yes __ No
11. Conjunctiva and sclera
__ Conjunctiva is color pink (normal)
__ Conjunctiva is color red
__ Conjunctiva is pale
__ Sclera is white (normal)
__ Sclera is red
__ Sclera is yellow

12. PERRLA
Pupils are equal

Pupils are round

__ Yes __ No
Pupils are reactive to light and accomodation
__ Yes __ No

__ Yes __ No

13. Extraocular muscle function (eye movement through the six cardinal directions of gaze)
Parallel movement
__ Yes __ No
Nystagmus involuntary rapid rhythmic movement
__ Yes __ No
Ears:
1. Symmetrical
__ Yes __ No
2. Discharge

__ Yes __ No
*If yes, what are the discharge
characteristics: __________________

__ Yes __ No
7. Have the same color as face
__ Yes __ No

3. Swelling
__ Yes __ No

8. Tenderness
__ Yes __ No

4. Redness
__ Yes __ No

9. Perforations
__ Yes __ No

5. Lesions/scaling
__ Yes __ No
*where: __________________

10. Bulging
__ Yes __ No

6. Flat and intact

11. Whisper test
Able to hear whisper on right ear
__ Yes __ No
Able to hear whisper on left ear
__ Yes __ No
12. Weber test
Sound is heard equally on both ears
__ Yes __ No
Sound is heard louder on the right ear
__ Yes __ No
Sound is heard louder on the left ear
__ Yes __ No
13. Rinne Test
Air conduction: _____ secs.
Bone conduction: _____ secs.
Positive rinne (air conduction > bone conduction) normal
__ Yes __ No
Conductive hearing loss (air conduction < bone conduction)
__ Yes __ No

MUSCULOSKELETAL SYSTEM

Gait: (Observe patient walk)

Normal and steady gait
_Yes _No, If No:
Propulsive gait
Scissors gait
Spastic gait
Waddling gait
Steppage gait
Balance:
Tandem walking
Heel and toe walking

Coordination:
Finger-thumb opposition
Finger to finger

Deep knee bends

Hopping
Romberg test (feet together, eyes open; then eyes
closed).
Posture:

Good standing posture

_Yes _No, If No
Kyphosis
Lordosis
Scoliotic

Finger to nose
Supination and pronation of the hands
Toe tapping
Run heel of one foot down the shin of the other leg
Joints and muscle characteristics:
Tenderness (Assess PQRST)
Provocation/PalliationQuality/QuantityRegion/RadiationSeverity ScaleTimingEdema
If yes:
____Non Pitting
__Bilateral __Unilateral

Temperature

Crepitus
Nodules

Fluid

Indicate temperature _________

Characteristic ____________________
Characteristic____________________
Range of Motion:
Temporomandibular joint
clench teeth
open & clothes mouth
Neck
Flexion
Extension
Rotation
Lateral bending
Spine
Forward flexion
Extension
Rotation
Lateral bending

Wrists
Flexes
Extends
Hyperextends
Moves side-to-side
Thumbs/fingers
Abduction
Adduction
Flexion

Knees
Flexion
Extension

____Pitting
__Bilateral __Unilateral
__Skin ulceration
__1+ slight pitting
__2+ deeper than 1+
__3+ noticeably deep pit
__4+ very deep pit

Shoulders
Forward flexion
Backward extension
Abduction
Adduction
Internal rotation
External rotation
Elbows
Flexion
Extension
Pronation
Supination
Extension
Hips
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation

Ankles
Dorsiflexion
Plantar flexion
Inversion
Eversion

Muscle Strength (Grade)

0/5: no contraction
1/5: muscle flicker, but no movement
2/5: movement possible, but not against gravity
3/5: movement possible against gravity, but not against resistance by the examiner
4/5: movement possible against some resistance by the examiner
5/5: normal strength

1.

1.

1.

Toes
Flexion
Extension
Adduction
Abduction

PERIPHERAL VASCULAR SYSTEM

Upper Extremities; Arm size and Venous Pattern
Arms bilaterally symmetric
__ Yes __ No
Minimal variation in size and shape
__ Yes __ No
Presence of edema
__ Yes __ No
Coloration of hands and arms
Same color bilaterally
__ Yes __ No
02. Temperature of fingers, hands and arms
Warm to touch bilaterally
__ Yes __ No
03. Capillary refill time
3 seconds or less
__ Yes __ No
If no, indicate: ____
04. Radial Pulse
Equal strength bilaterally
__ Yes __ No
Pulse Rate: ____
05. Epitrochlear lymph nodes
Not palpable
__ Yes __ No
If yes indicate:
Size ____
Presence of tenderness
__ Yes __ No
06. Patency of the radial and ulnar pulse
Ulnar: Pink coloration returns to the palms within 3-5 seconds __ Yes __ No
If no, indicate time of return: ___
Radial: Pink coloration returns to the palms within 3-5 seconds
__ Yes __ No
If no, indicate time of return: ___
2. Lower Extremities; Legs
Skin color
Changes in pigmentation
__ Yes __ No
Indicate color of the skin: ___________
02. Distribution of hair
Hair covers the skin of the legs
__ Yes __ No
Hair appears on the dorsal surface of the toes
__ Yes __ No
03. Lesions and ulcers
Presence of lesions and ulceration
__ Yes __ No
If yes:
Smooth and even margins
__ Yes __ No
Irregular edges __ Yes __ No
Bleeding
__ Yes __ No
Location _______ (toes, lateral ankle=arterial sufficiency; medial ankle=venous insufficiency)
04. Edema

Presence of edema
__ Yes __ No
If yes:
____Non Pitting
__Bilateral __Unilateral

____Pitting
__Bilateral __Unilateral
__Skin ulceration
__1+ slight pitting
__2+ deeper than 1+
__3+ noticeably deep pit
__4+ very deep pit

05. Temperature of feet and legs

Equally warm bilaterally __ Yes __ No
Indicate temperature:
__Cold to touch (arterial insufficiency)
__Warm to touch
__Increased warmth upon touch (superficial thrombophlebitis)
06. Superficial inguinal lymph nodes
Tender
__ Yes __ No
Movable__ Yes __ No
Indicate size: ____(cm)
07. Femoral Pulse
Strong and equal bilaterally

__ Yes __ No

08. Varicosities and Thrombophlebitis

Veins are flat barely seen under the surface of the skin
__ Yes __ No
Presence of varicose veins
__ Yes __ No
If yes:
Distended
__ Yes __ No
Nodular __ Yes __ No
Bulging __ Yes __ No
Tortuous__ Yes __ No
Indicate location: _________________
Presence superficial venous thrombophlebitis
__ Yes __ No
If yes:
Redness
__ Yes __ No
Thickening
__ Yes __ No
Tender
__ Yes __ No
Aching or cramping upon walking __ Yes __ No
Dorsiflexion of the foot
__ Yes __ No
Swelling/inflammation
__ Yes __ No
NOSE AND SINUSES
Rhinorrhea
__ Yes __ No
Epistaxis
__ Yes __ No
Obstruction of airflow
__ Yes __ No
Sinus pain
__ Yes __ No
Location: ______________
Itching __ Yes __ No
Location:_______________
Anosmia
__ Yes __ No
Nasal trauma
__ Yes __ No
When: ________
Sneezing
__ Yes __ No
Watery eyes
__ Yes __ No

MOUTH AND THROAT

Dental/ Throat Surgery
__ Yes __ No
When: ______________ Type of Surgery: ______________
Hoarseness or recent voice change __ Yes __ No
Missing Teeth
__ Yes __ No
_____Upper
_____ Lower
___Quantity
Oral lesions
__ Yes __ No
Location ______________
Bleeding gums
__ Yes __ No
Sore throat
__ Yes __ No
When did it start ___________
Use of denture
__ Yes __ No
Full denture ____Partial denture ____Upper ____Lower
Uvula midline
__ Yes __ No
Dysphagia
__ Yes __ No
NUTRITION
Height:_______ Weight: _______ BMI: _____
___ Diabetes
___ Gastritis
___ GERD
___Nausea and Vomiting
___Hepatomegaly
___ Other: ( Pls Specify) _________________
Food allergy: ____Yes
____No
Specify: ________
Number of meals: _______
Number of snacks: ______
Type of food: (Check that all apply)
____Vegetable
Frequency______ x a day/week.
____ Fish
Frequency _______x day/week.
____ Meat
Frequency ______x a day/ week.
____ Poultry
Frequency ______x a day/ week.
Oral Fluid Intake
Type of fluid intake:
_____Water
Amount: _______
_____ Caffeinated drinks Amount: ______
_____ Sugary ( Sodas)
Amount : ______
_____ Others ______
Amount: _______
_____ Unwanted Weight Loss
How many lbs/ kg? ________
Use of Dietary Supplements?
Yes_____
Pls Specify: __________
Elimination
Difficulty in voiding;
Pain during urination:
Color: _______
Amount: ______
____Nocturia
____Anuria
____Oligoria
Difficulty in defecating: ___ Yes
Color: __________
Appearance:___________
Frequency: ____x a day

___ Yes
___No
___ Yes ___No

___No

No ______

____Diarrhea
___Constipation
Bowel Sound:
___ Hyperactive
____ Hypoactive
____ Normal
NERVOUS SYSTEM ASSESSMENT

Correctly identifies scent

Wears prescription glasses

____Yes ____No
If yes, grade of prescription glasses _______
Duration of wear _______

Reads Jaegers chart

Findings: ________

____Yes ____No

Ptosis

____Yes ____No

Coordinated motion in 6 cardinal fields

____Yes ____No

Nystagmus

____Yes ____No

PERRLA

____Yes ____No

Temporal and masseter muscles contract

____Yes ____No

Identifies sharp and dull stimuli

____Yes ____No

Corneal reflex

____Yes ____No

Performs facial gestures

____Yes ____No
___Smile ____Frown _____Puff out cheeks _____Raise eyebrows

Identifies correct flavor in taste test

____Yes ____No
____Bitter ____Salty _____Sweet

Whisper test heard

Weber test
____Both ears

____Yes ____No

____Yes ____No
____Yes ____No
____Bad ear _____Good ear

Rinne test
____Air conduction time

____Yes ____No
____Bone conduction time

Gag reflex present

____Yes ____No

Uvula and soft palate rise symmetrically

____Yes ____No

Dysphagia

____Yes ____No

Shrugs shoulders symmetrically

____Yes ____No

Turns head against resistance

____Yes ____No

Tongue movement symmetric

____Yes ____No

Tongue moves against resistance

____Yes ____No

Upper extremity muscle strength

____5+ ____4+ ____3+ ____2+ ____1+

Lower extremity muscle strength

____5+ ____4+ ____3+ ____2+ ____1+

Muscle atrophy

Symmetrical muscles
____Yes ____No
If not, location of muscle _____________________

Involuntary movements
____Yes ____No
____Fasciculations ____Tics ____Tremors ____Slow movements ____Bried rapid movements

Steady gait

Able to tandem walk

Romberg test
____Normal

____Yes ____No
If yes, location of muscle _____________________

____Yes ____No
____Cerebellar Ataxia
____Parkinsonian Gait
____Scissors Gait
____Spastic Hemiparesis ____Footdrop (Steppage gait)

Coordination intact

Upper extremity

____Yes ____No
____Positive
____Yes ____No

____ Finger to nose

_____Finger to thumb

_____Turns palms up and down

Lower extremity
____Heel to shin

Sensory intact

____Yes ____No
____Pain sensation ____Temperature differentiation ____Vibratory sensation
____Sensitivity to position ____Tactile discrimination ____ 2 point discrimination

Reflexes present

Biceps reflex

____4+ ____3+ ____2+ ____1+ ____0

Brachioradialis reflex

____4+ ____3+ ____2+ ____1+ ____0

Triceps reflex

____4+ ____3+ ____2+ ____1+ ____0

Patellar reflex

____4+ ____3+ ____2+ ____1+ ____0

Achilles reflex

____4+ ____3+ ____2+ ____1+ ____0

Plantar reflex

____Yes ____No

____Flexion

____Dorsiflexion ____Fanning of toes (+Babinski)

REPRODUCTIVE ASSESSMENT

1.
a.
b.
c.
d.
e.
f.
g.
h.
i.

Female Reproductive Assessment

Breast
Recent increase of size of breast
__Yes __ No
Inflammation of breastq
__ Yes __ No
Presence of Edema in the breast
__ Yes __ No
Presence of redness in the breast
__ Yes __ No
Red, scaly, crusty areas in the areola
__ Yes __ No
Retracted Nipples
__ Yes __ No
Spontaneous discharged in the nipples
__ Yes __ No
Dimpling and retraction in the breast
__ Yes __ No
1-5 cm round, oval, mobile, firm, solid, elastic, non tender mass when palpated _ Yes_No

a.
b.
c.
d.
e.
f.
g.
h.

2. External Genitalia
Absence of pubic hair
__ Yes __ No
Lice or mits in the pubic hair
__ Yes __ No
Lesions in the Labia Majora
__ Yes __ No
Swelling in the Labia Majora
__ Yes __ No
Asymmetric Labia Majora
__ Yes __ No
Lesions, swelling, bulges, discharge, in the vaginal opening __ Yes __ No
Swelling, pain, discharge, in the bartholins gland
__ Yes __ No
Drainage and Discharged in the urethra
__ Yes __ No

a.
b.
c.
d.
e.
f.
g.
h.

3. Internal Genitalia
Absent or decreased vaginal muscle tone during palpation
__ Yes __ No
Bulging of the anterior vaginal wall
__ Yes __ No
Bluish Cervix
__ Yes __ No
Inflamed cervix
__ Yes __ No
Cervical enlargement of 3cm
__ Yes __ No
Asymmetric , reddened areas , strawberry spots, and white spots in the cervix _ Yes _ No
Malodorous, irritating discharged in the cervix
__ Yes __ No
Reddened areas, lesions in the vagina
__ Yes __ No

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

4. Male Reproductive System

Absence of pubic hair
Lice and egg mites in the pubic hair
Rashes, lesions, lumps in the skin of the penis
Hardness along the ventral surface of the penis
Tenderness in the penis
Discoloration of the foreskin
Yellow discharge from penis
Clear white discharge from penis
Enlarged scrotal sac
Rashes, lesions, inflammation, of scrotal skin
Palpable tortuous vein in the scrotal area
Bulges in the external inguinal rin
Bulge or mass in inguinal area
Bulge or mass in the inguinal femoral area

HEAD
Inspection of Head:
Symmetric
Midline
Inspection of Face:
Shape of Face
Oval

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
__ Yes __ No
__ Yes __ No
__ Yes __ No

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No

Round
Rectangle
Heart
Triangle
Inverted Triangle
Square
Diamond
Oblong
Symmetric
Presence of involuntary/abnormal movement
Palpation of Head:
Hard
Smooth
Presence of lesions
Temporal Artery:
Elastic
Tender
Temporomandibular Joint:
Swelling
Tenderness
Crepitus upon movement
NECK
Inspection of Neck:
Symmetric
Presence of lumps or masses
Swelling
Presence of upward movement of
thyroid cartilage, cricoid cartilage
and thyroid gland upon swallowing
Palpation of Neck:
Trachea is midline
Thyroid Gland:
Palpable
Smooth
Firm
Non-tender
Auscultation of Neck:
Presence of bruits

___ Yes
___ Yes
___ Yes
___ Yes
___ Yes
___ Yes
___ Yes
___ Yes

___ No
___ No
___ No
___ No
___ No
___ No
___ No
___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

___ Yes
___ Yes
___ Yes
___ Yes

___ No
___ No
___ No
___ No

___ Yes ___ No

___ Yes
___ Yes
___ Yes
___ Yes

___ No
___ No
___ No
___ No
___ Yes ___ No

PALPATION: LYMPH NODES OF THE HEAD AND NECK

Preauricular Nodes
___ Swelling
___ Enlargement
___ Tenderness
Postauricular Nodes
___ Swelling
___ Enlargement
___ Tenderness
Occipital Nodes
___ Swelling
___ Enlargement
___ Tenderness
Tonsillar Nodes
___ Swelling
___ Enlargement
___ Tenderness
Submandibular Nodes
___ Swelling
___ Enlargement
___ Tenderness
Submental Nodes
___ Swelling
___ Enlargement
___ Tenderness
Superficial Cervical Nodes
___ Swelling
___ Enlargement
___ Tenderness
Posterior Cervical Nodes ___ Swelling
___ Enlargement
___ Tenderness
Deep Cervical Chain Nodes
___ Swelling
___ Enlargement
___ Tenderness
Supraclavicular Nodes
___ Swelling
___ Enlargement
___ Tenderness
THORAX AND LUNGS
Inspection:
Nasal Flaring
___Yes ___ No
Pursed Lip Breathing
___ Yes ___ No
Color of Face, Lips, and Chest

Even without unusual or prominent discoloration

Ruddy-Purple
Cyanotic
Color and Shape of Nails:
Pinkish
Pale
Cyanotic
160-degree angle between the base and the skin
180-degree angle (Early Clubbing)
>180-degree angle (Late clubbing)

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

Posterior Thorax:
Inspection:
Shoulders, Scapulae, and Spinous Process
Scapulae symmetric and non protruding
___ Yes ___
Shoulders and Scapular are at equal horizontal position ___ Yes ___
Ratio of anteroposterior to transverse diameter (1:20)
___ Yes ___
Spinous process; Straight
___ Yes ___
Thorax:
Symmetric with ribs
Spinous deviate laterally
Barrel chest
Use of Accessory Muscles
Clients Positioning:
Sitting up, relaxed, and breathing easily
Tripod position
Palpation:
Tenderness and Sensation
Tenderness, Pain or Unusual Sensation
Temperature equal bilaterally
Muscle soreness
Crepitus
Surface Characteristics:
Skin and Subcutaneous Tissue
Lesions
Masses:
Palpable
Movable
Hard
Soft

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No
No
No
No

___ Yes ___ No

___ Yes ___ No

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No

___ Yes ___ No

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No

Fremitus:
Symmetric
Easily Identified
Unequal fremitus
Diminished fremitus

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

Chest Expansion:
Expands symmetrically (5-10 cms apart)

___ Yes ___ No

Percussion:
Resonance
Hyperresonance

___ Yes ___ No

___ Yes ___ No

Dull
Flat Tones
Diaphragmatic Excursion:
Equal bilaterally (3-5cms)
Level of Diaphragm higher on the right
Descent limited
Auscultation:
Breath Sounds:
Bronchial
Bronchovesicular
Vesicular
Diminished
Absent
Louder breath sounds
Adventitious sounds
Crackles
Continuous Sounds
Wheeze
Voice Sounds:
Bronchophony: 99
Voice transmission:
Soft
Muffled
Indistinct
Words easily understood
Loud
Egophony: E
Soft
Muffled
Letter E distinguishable
Louder ___ Yes ___ No
Sounds like A ___ Yes ___ No
Whispered Pectoriloquy: 1-2-3
Transmission Sounds:
Faint
Muffled
Inaudible
Clear
Distinct
Anterior Thorax:
Inspection:
Shape and Configuration:
Anterior diameter < transverse diameter (1:2)
Barrel Chest
Position of Sternum
Midline and Straight
Funnel Chest
Pigeon Chest

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No
No

Fine ___

Coarse ___

Sibilant ___ Sonorous ___

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

Sternal Retractions
Slope of Ribs:
Slope
Symmetric ICS
Costal Angle within 90 degrees
Barrel Chest Configuration

___ Yes ___ No

Downward ___ Upward ___
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

Quality and Pattern of Respirations:

Relaxed
Effortless
Quiet
Labored
Noisy
Tachypnea
Bradypnea
Hyperventilation
Hypoventilation
Cheyne Stokes Respirations
Biots Respiration

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

Intercostal Spaces:
Retractions
Bulging

___ Yes ___ No

___ Yes ___ No

Use of Accessory Muscles

___ Yes ___ No

Palpation:
Tenderness over thoracic muscles
Tenderness at Costochondral junction of Ribs
Crepitus
Surfaces Masses
Palpable
Movable
Hard
Soft
Fremitus
Symmetric bilaterally
Easily identified
Diminished vibrations
Anterior Chest Expansion
Symmetrical
Unsymmetrical
Percussion:
Resonance
Hyperresonance
Dull
Flat TonesAuscultation:
Breath Sounds:
Bronchial
Bronchovesicular
Vesicular
Diminished
Absent
Louder breath sounds

No
No
No
No
No
No
No
No
No
No
No

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No
No

No
No
No
No
No
No
No
No
No
No
No
No

Adventitious sounds
Crackles
Continuous Sounds
Wheeze

Fine ___

Coarse ___

Sibilant ___ Sonorous ___

Voice Sounds:
Bronchophony: 99
Voice transmission:
Soft
Muffled
Indistinct
Words easily understood
Loud

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No

Egophony: E
Soft
Muffled
Letter E distinguishable
Louder
Sounds like A

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No

Whispered Pectoriloquy: 1-2-3

Transmission Sounds:
Faint
Muffled
Inaudible
Clear
Distinct

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No
No

ABDOMEN
Inspection:
Symmetry:
Concave:
Convex:
Round:
Flat:
Color of the skin:
Cullens sign (bluish discoloration)
Jaundice (yellowish discoloration)
Striae / Strech mark
Scars
Auscultation:
Bowel sound: (rate per quardrant)
Quadrant 1:
Quadrant 3:
Vascular sound:
Low pitched:
Murmur like sound:
Percussion;
Tymphany:

___ Yes ___

___ Yes ___
___ Yes ___
___ Yes ___

No
No
No
No

___ Yes ___ No

___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

Quadrant 2:
Quadrant 4:
___ Yes ___ No
___ Yes ___ No
___ Yes ___ No

Resonance:
Dullness:

___ Yes ___ No

___ Yes ___ No

Palpation:
Tenderness:
___ Yes ___ No
Location: (which quadrant):___________________
Deep palpation: rate:
Palpate masses:
Abdominal pain

___ Yes ___ No

Location /site: __________________

Onset of pain:___________________
Character:
Stabbing:
___ Yes ___ No
Aching:
___ Yes ___ No
Burning:
___ Yes ___ No
Duration:
Worse: _______________
Better: ________________
Stayed the same: ________
Severity: (pain scale 1-10) ______________
1- very slight of pain-10 being the
highest:

Vomiting:
___ Yes ___ No
Diarrhea:
___ Yes ___ No
Fever:
___ Yes ___ No
Weight loss:
___ Yes ___ No
Fatigue:
___ Yes ___
Yellowish of the eye skin:
___ Yes ___
Loss or change in appetite:
___ Yes ___
Change in bowel elimination:
___ Yes ___
How many times per
day:_______________

Associated symptoms:
-Nausea:

No
No
No
No

___ Yes ___ No

1.
Presence of Skin Problems
Rashes
___ Yes ___ No
Dryness
___ Yes ___ No
Oiliness
___ Yes ___ No
Dryness
___ Yes ___ No
Bruising
___ Yes ___ No
Swelling
___ Yes ___ No
Increased Pigmination
___ Yes ___ No
Location:_______________
2.
Birthmarks

___ Yes ___ No

If yes, Location:__________

3.

Body Piercing
___ Yes ___ No
If yes, Location: __________

4.

Color Variation
___ Yes ___ No
If yes, Location: _________

5.

Lesion

6.

Texture

___ Yes ___ No

Location: _____________
Type: _________________

Smooth ___ Yes ___ No

Rough
___ Yes ___ No
7.
Moisture
Moist
___ Yes ___ No
Dry
___ Yes ___ No
3.
Edema
___ Yes ___ No
Grade of Edema:__________
NAILS
1.
Color:______________
2.
Shape:______________
HAIR / SCALP
1.
Moisture

Dry
___ Yes ___ No
Moist
___ Yes ___ No
2.
Distribution:

Well Distributed ___ Yes ___ No

Hair loss
___ Yes ___ No