Comprehensive Health Paper

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Pages: 4

Copyright © 2004, 2002 Saunders Inc. All Rights Reserved
Jarvis: Physical Exam and Health Assessment, 4th Edition Complete Physical Examination Form Chapter 28: The Complete Health Assessment: Putting It All Together Date ________________
Patient _____________________________ Age _____ Sex _____ Occupation ________
Examiner ____________________________________
General Survey of Patient
1. Appears stated age
2. Level of consciousness
3. Skin color
4. Nutritional status
5. Posture and position
6. Obvious physical deformities
7. Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement
8. Facial expression
9. Mood and affect
10. Speech: articulation, pattern, content appropriate, native language
11. Hearing
12. Personal hygiene
Measurement and Vital Signs
1. Weight
2. Height
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3. Skinfold thickness, if indicated
4. Vision using Snellen eye chart OD _____OS _____Correction?
5. Radial pulse, rate, and rhythm
6. Respirations, rate, depth
7. Blood pressure Right arm __________________________(sitting or lying?) Left arm __________________________(sitting or lying?)
8. Temperature (if indicated)
9. Pain assessment
STAND IN FRONT OF PATIENT, PATIENT IS SITTING
Skin
1. Hands and nails
2. (For rest of exam, examine skin with corresponding region) Color and pigmentation Temperature Moisture Texture Turgor Any lesions
Head and Face
1. Scalp, hair, cranium
2. Face (cranial nerve VII)
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3. Temporal artery, temporomandibular joint
4. Maxillary sinuses, frontal sinuses
Eyes
1. Visual fields (cranial nerve II)
2. Extraocular muscles, corneal light reflex Cardinal positions of gaze (cranial nerves III, IV, VI)
3. External structures
4. Conjunctivae Sclerae Corneas Irides
5. Pupils
6. Ophthalmoscope, red reflex Disc Vessels Retinal background
Ears
1. External ear
2. Any tenderness
3. Otoscope, ear canal Tympanic membrane
4. Test hearing (cranial nerve VIII), voice test Weber test
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Rinne test
Nose
1. External nose
2. Patency of nostrils
3. Speculum, nasal mucosa Septum Turbinates
Mouth and Throat
1. Lips and buccal mucosa Teeth and gums Tongue Hard/soft palate
2. Tonsils
3. Uvula (cranial nerves IX, X)
4. Tongue (cranial nerve XII)
Neck
1. Symmetry, lumps, pulsations
2. Cervical lymph nodes
3. Carotid pulse (bruits if indicated)
4. Trachea
5. ROM and muscle strength (cranial nerve XI)
MOVE TO BACK OF PATIENT, PATIENT SITTING
6. Thyroid gland
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Chest and Lungs, Posterior and Lateral
1. Thoracic cage configuration Skin characteristics Symmetry
2. Symmetric expansion Tactile fremitus Lumps or tenderness
3. Spinous processes
4. Percussion over lung fields Diaphragmatic excursion
5. CVA tenderness
6. Breath sounds
7. Adventitious sounds
MOVE TO FRONT OF PATIENT
Chest and Lungs, Anterior
1. Respirations and skin characteristics
2. Tactile fremitus, lumps, tenderness
3. Percuss lung fields
4. Breath sounds
Upper Extremities
1. ROM and muscle strength
2. Epitrochlear nodes
Breasts
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1. Symmetry, mobility, dimpling
2. Supraclavicular and infraclavicular areas
PATIENT SUPINE, STAND AT PATIENT’S RIGHT
3. Breast palpation
4. Nipple
5. Axillae and regional nodes
6. Teach breast self-examination
Neck…