REVISED CHECKLIST OF PHYSICAL

EXAMINATION RESULTS

_______________________________
Student Examiner

Version 1.1

( To be used as recording system for Cephalocaudal Examination results)

CARDIO VASCULAR SYSTEM

A. Bulging of Neck Veins ___ Present ___ Absent

B. Quality of Carotid Pulsation during Palpation ( Compare both Sides)

Rhythm of Pulsation: ____ Rhythmic ___ NonRhythmic

Intensity of Pulsation: ____ Regular ___ Bounding ____ Weak

Symmetry: ___ Symmetrical ____ Assymetrical

C. Capillary Refill Time

Nail Color: ____ Pinkish ____ Pale ____ Cyanotic

Upper extremity ( Right ) ____ immediate to 2 Sec

____ more than 2 sec

Upper extremity ( Left) ____ immediate to 2 Sec

____ more than 2 sec

D. Quality of Peripheral Pulsation ( Upper Extremities - Brachial and Radial Sites)

Rhythm of Pulsation: ____ Rhythmic ___ NonRhythmic

Intensity of Pulsation: ____ Regular ___ Bounding ____ Weak

Symmetry: ___ Symmetrical ____ Assymetrical

D. Quality of Peripheral Pulsation ( Lower Extremities - Femoral, Posterior Tibialis, Popliteal and
Dorsalis Pedis Sites)

Rhythm of Pulsation: ____ Rhythmic ___ NonRhythmic

Intensity of Pulsation: ____ Regular ___ Bounding ____ Weak

Symmetry: ___ Symmetrical ____ Assymetrical

E. Quality of Apical Pulsation during Palpation ( R Sub Clavicular, L Sub Cavicular, Apex)

Rhythm of Pulsation: ____ Rhythmic ___ NonRhythmic

Intensity of Pulsation: ____ Regular ___ Bounding ____ Weak

E. Apical Heart Rate (PMI) : _____ ( Bpm)

____ Regular ____ Tachycardic _____ Bradycardic

F. Quality of Apical Pulsation during Auscultation ( R Sub Clavicular, L Sub Cavicular,

L 2nd-5th ICS , Apex)

Heart Sounds: ____ Regular ____ Adventitious

a.____ Gallops
b.____ Murmurs

NARRATIVE DISCUSSION OF CARDIOVASCULAR SYSTEM FINDINGS:

RESPIRATORY SYSTEM

A. Observe for quality of Respiration

____ Eupnic ____Dyspnic

B. Check Respiratory Rate

____ (Cpm)

C. Observe for Anterior View and AP View of Chest ( Check ratio)

____ Normal ____ Pectus Excavatum ____ Pectus Carinatum

D . Perform Tactile Frimitus ( Posterior)

____ Regular ____ Increased Vibration ____ Diminished Vibration

E. Lung Expansion

____ Regular/ Symmetrical

____ Assymmetrical

E. Percussion Sound @ Lung Field

____ Resonant _____ Dull _____ Flat _____ Tympanic

F. Auscultate Breath Sounds ( Posterior and Anterior)

____ Clear ____ Adventitious

a. ____Wheezing

b .____ Crackles

c. ____ Others

G. Presence of Cough

____ None ____ Present

a.____ Productive

b____. Non Productive

NARRATIVE DISCUSSION OF RESPIRATORY SYSTEM FINDINGS:

MUSCULOSKELETAL SYSTEM

A. Mobility

_____ Ambulatory
Observe for Gait: Observe for Posture
_____ Effortless ______ Erect
_____ Spastic ______ Scoliotic
_____ Waddling ______ Lordotic
_____ Zigzagging

_____ Ambulates with assistance or with assistive device

_____ not ambulatory

B. Presence of Musculoskeletal deformity

______ Present Specify ____________________________________

______ None

C. Presence of any Orthopedic Device

______ None
______ Cast
______ Traction
______ Prosthesis
______ Others

Specify / Describe______________________________________________
D. Muscle Tone/Strength ( Tardieu Scale)
_____ No resistance through passive movement
_____ Slight Resistance through Passive movements

______ Presence of Clonus at certain angles

______ Rigid limb and Joint

E. Range of Motion
______ Full ______ Partial

F. Presence of Pain
______ Present Pain Score _______
______ Present only During Ambulation
______ Absent

NARRATIVE DISCUSSION OF MUSCULOSKELETAL SYSTEM FINDINGS:

SENSORY PERCEPTION
Eyes

A. Eyebrows and Eyelids

______ No structural aberration/ Symmetrical
______ Ptosis _____ Right ____ Left _____ Both
B. Conjunctiva
_____ Pinkish
_____ Reddish
_____ Pale
C. Sclera
_____ White
_____ Reddish
_____ Yellowish

D. Visual Acuity
_____ Normal _____ Far Sighted _____Near Sighted
E. Six Cardinal Fields of Gaze
_____ Normal/ Symmetrical ______ Assymetrical
F. Cover/ Uncover
_____ Stable _____ Unstable
G. Corneal Reflex
_____ Aligned _____ Not Aligned/ Not Centered
H. Pupillary Reflex
_____ PERRLA _____ non PERRLA

Ears

A. External Ear
_____ Symmetrical _____ Non Symmetrical

B. Ear Canal
______ Patent _____ Excessive Cerumen

C. Whisper Test
______ Receptive
 ______ Has Difficulty Hearing
______ Non Receptive
Specify Results ____________________________

Webber’s Test ______ Lateralization ______ No Lateralization

Rinne’s Test ______ ( +) _______ (-)

Nose

A. External Structure
_______ Regular/ Symmetrical _____ Obvious Deformity

B. Nostrils
______ Patent and intact
______ Obstructive
______ Excessive secretions

C. Sense of Smell
______ Intact _____ Has difficulty ______ Absent

NARRATIVE DISCUSSION OF SENSORY PERCEPTION FINDINGS:

INTEGUMENTARY SYSTEM

A. Skin Integrity

_________ Intact
_________ Lesions / Ulcerations
Specify Location______________________________
_________ Rashes
Specify Location______________________________
_________ Bruising
Specify Location _____________________________

B. Skin Color

________ Regular

________ Discoloration Noted

______ Erythema
______ Cyanosis
______ Pallor

C. Skin Temperature
_____ Regular
_____ Warm to touch
_____ Cold and Clammy

D. Edema
___________ Absent
___________ Present
_____ +1 _____ +2 ______+3 ______ +4
 NARRATIVE DISCUSSION OF INTEGUMENTARY SYSTEM FINDINGS:

GASTROINTESTINAL SYSTEM
A. Appetite
_______Normal ______ Loss of Appetite

B. Oral Mucosa

______ Pinkish ______ Pale ______ Bleeding Noted

C. Teeth
______ Well Embedded
______ Incomplete/ Dental Carries Noted

D. Bowel Sound
_____ Normal
_____ Hypoactive
_____ Hyperactive
_____ Absent
 E. Abdominal Pain

_____ Present _____ Absent

Location ________________
Rebound Tenderness ____ (+) _____ (-)
Boardlike abdomen ____ (+) _____(-)
F. Vomitting

_____ Present ______ Absent

Frequency ( With in 24 hrs) ________

G. Bowel Movement

_________ Regular
Frequency ( Last 24 hrs) _________

_________ Loose Bowel Movement

Frequency ( Last 24 hrs) __________

_________ Constipated
Frequency ( Last 24 hrs) __________

NARRATIVE DISCUSSION OF GASTROINTESTINAL SYSTEM FINDINGS:

NEUROLOGIC

Level of Consciousness

____ Fully Conscious

____ Lethargic

____ Stuporous

____ Comatose

Coherence ____ Coherent ____ Incoherent

Orientation ____ Oriented ____ Disoriented

Mood and Affect ____ Appropriate ____ Inappropriate ____ Flat

Cerebellar Function ( Upper Extremity )

Rapid Alternating Movement ____ Coordinated

____ Uncoordinated

Finger to Nose ____ Coordinated

____ Uncoordinated

Finger- Thumb ____ Coordinated

____ Uncoordinated

Alternating Touch to Nose ____ Coordinated

 ____ Uncoordinated

Cerebellar Function ( Lower Extremity )

Heel- Shin Test ____ Coordinated

____ Uncoordinated

Gait ____ Coordinated

____ Uncoordinated

Balance

Tandem Walk ____ Balanced

____ Imbalanced

Rombergs Test ____ Balanced

____ Imbalanced

Deep Tendon Reflexes

Site +1 +2 +3 +4
Brachial
Tricep
Patellar

Babinski Reflex ____ (+) ____ (-)

NARRATIVE DISCUSSION OF NEUROLOGIC SYSTEM FINDINGS
LYMPHATIC SYSTEM

Tonsils ___(+1) ____ (+2) ____ (+3) ____ (+4)

Lymph Nodes Palpable Non Tender Non Tender

Palpable
Pre Auricular
Post Auricular
Occipetal
Sub Mental
Sub Mandibular
Tonsillar
Superficial Cervical
Deep Cervical Chain
Posterior Cervical
Supraclavicular

NARRATIVE DISCUSSION OF LYMPHATIC SYSTEM FINDINGS

COPING PATTERN

Any recent changes in patient's life (job, divorce,death,major surgeries,recent abuse)

Identify issues in Self Image if there is any.

Coping Techniques employed in dealing with stress