Health Assessment Script PDF

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Hi my name is _______. I will be completing my health assessment on my Volunteer patient ________. Good afternoon. I understand you are here for a physical. Is it ok if I complete a comprehensive assessment on you?

Can you tell me your:  Name:  DOB:  Do you know where you are:  What year is it:  He is alert and oriented x4  Do you have medical issues or medications you take?  His nutritional status is Well-developed  His posture is upright  I am assessing for physical deformities or any obvious mobility limitations  His facial expression is appropriate for the situation  His mood and affect is appropriate  His speech is clear and appropriate  His personal hygiene is clean and kempt  Do you wear hearing aids?  Can you tell me your height:  Can you tell me your weight:  I will calculate BMI by CONVERTING WT IN LBS TO KG (WT DIVIDED BY 2.2) & CONVERT HEIGHT IN INCHES TO METERS. FORMULA IS THEN WEIGHT IN KG/HEIGHT IN METERS SQUARE.

 I will now check his vital signs

- I am going to check your radial pulse on your wrist. I am going to count it for 30 seconds and multiply by 2 __ - His pulse is regular. I am now going to count your breathing for 30 seconds and multiple by 2 __ - I am assessing if his breathing is regular or irregular andif it is labored or unlabored - I am now going to check your blood pressure. I am wrapping the cuff around his arm, I will pump it up and slowly release to listen with my stethoscope and note the blood pressure ___  Are you in any pain? Scale of 0-10

HANDS  I will assess your hands now: both hands  I am looking for warmth of the hands, swelling, if his hands are dry or moist  I am assessing his nails looking for nail ridges, clubbing of fingers, yellowness, or thickness  Capillary refill is less than 2 sec on both LEFT and RIGHT hand  His color is consistent with ethnic background  There are no lesions/sores  The texture is smooth and turgor is non-tenting

HEAD AND FACE  I am going to assess his head and scalp, and hair  I am assessing to see if there are any lesions, lumps, scaling, or evidence of trauma.  Do you have any tenderness? Or any other issues with your head?  Now I’m going to assess cranial nerve 7- can you frown for me, smile for me, show me your teethand puff out your checks? No abnormalities seen.

EYES  I am going to assess his eyes now. I am assessing for ptosis, lid lag, discharge, crusting. He has even hair distribution, his eyes and eyebrows are symmetric. There is no jaundice, lesions or redness. His sclera color is white  Have you had any problems with your eyes?  I am now going to shine a light in his eyes to assess pupils and assess the color of sclera looking for any discoloration. I am assessing for size, if they are equal, round, and that they react to light.  His pupils are __ mm at rest on left and __mm at rest on right His left eye is __ mm constricted and __ mm constricted on right  Can you look at my light as I bring toward you- I am assessing for pupils accommodating

 I am going to test his cranial nerve 2 assessing for confrontation. Can you place this piece of paper over one eye? Can you say now when you see my finger? (**TO PERFORM: Bring in fingers from side and then, Bring my hand in beside the face without the paper and tell me when you can see it. ) Let me know when you see my fingers. Then we’re going to do the other eye.  Cranial nerve 2 is intact, no abnormalities  I will now assess extraocular muscles.  Can you follow my finger with your eyes without turning your head- (**TO PERFORM: Do the H and then an x)  Extraocular muscles are intact  I am going to assess his corneal light reflex: I am going to shine the light in your eyes one more time. If you can focus on the light for me. I am assessing to determine if reflex is present and symmetrical.

EARS  I am assessing both ears-looking for lesions, tenderness, or drainage.  Are you having any ear issues, ringing in your ears or tenderness?  Do you wear hearing aids?

NOSE  I am assessing his nose- I am looking for symmetry, drainage, or redness. (**TO DO: PALPATE NOSE)  Any tenderness or pain or issues with your nose?  I am testing the patency of his nostrils- place your finger on one side of nose= Sniff, now do the other side. Are your nostrils are patent?  Do you get nosebleeds?

MOUTH AND THROAT  How many times a day do you brush your teeth?  Do you floss daily?  When was your last dental visit? ____  Do you gums bleed easily or any bleeding noted?  I am going to check his mouth, tongue, teeth, and gums- (**TO DO: USE PENLIGHT)  I am assessing his lips- for color, to determine if moist or dry. Can you open your mouth for me? I am looking at color and moisture.  His teeth are not discolored and no signs of caries. I am looking at color and moisture  His gums are not red or swollen  His tongue is moist and pink

 I am now going to assess his cranial nerves 9 and 10 and uvula to ensure intact and asses if midline. Using the handle of the spoon as a prop for a tongue depressor. Can you say ahh.  His uvula is intact and midline. I would also assess gag reflux intact, but just simulating it now.

Neck  I am assessing his neck. Assessing for lumps or lesions. - Any issues with your neck?  I am going to assess his carotid pulse but palpating one at a time - They are palpable  Assessing his trachea and it is midline  I am checking is ROM and muscle strength assessing Cranial nerve 11  Can you move your head around and turn your head from side to side, can you press against my hands side to side and forward and back?  Can you shrug your shoulders? Now against my hands  He has full ROM with his neck and can shrug his shoulders. Cranial nerve 11 is intact.

Posterior chest and lungs Now I will assess his posterior chest- (**TO DO: have back facing camera  I am assessing his thoracic cage- Feel thoracic area it is symmetrical with no use of accessory muscles. No barrel chest. Symmetric expansion.  Any pain or tenderness?

 I am going to assess for tactile fremitus. Lt and RT. I’m going to put a hand on each area of the back - Can you say 99 and repeat until I’m done.  No lumps or tenderness present  Now I will Assess costovertebral (CVA) angle for tenderness: (**TO DO: Put left hand flat between 12th rib and spine on back and thump with right fist) -Do you feel any tenderness?  I am listening to his posterior breath sounds  RUL  RML  RLL  LUL  LLL - I am listening for any diminished breath so crackles, and wheezes.

- Lungs are clear to auscultation.

Anterior chest and lungs (**TO DO: Turn pt facing forward)  I am assessing his thoracic cage- Feel thoracic area it is symmetrical with no use of accessory muscles. No barrel chest. Symmetric expansion.  Any pain or tenderness?  I am going to assess for tactile fremitus. Lt and RT. I’m going to put a hand on each area of the chest - Can you say 99 and repeat until I’m done.  I am listening to his anterior breath sounds  RUL  RML  RLL  LUL  LLL - I am listening for any diminished breath sounds, rhonchi, crackles, and wheezes. -Lungs are clear to auscultation

HEART

 I am checking his apical impulse: I’m going to PALPATE FIRST. Palpable. Apex (bottom) just under nipple  Now I am going to listen to his apical pulse- Bottom of heart in same place. I’m going to LISTEN FOR 60 SECONDS so just bear with me for a minute. His rate is ___ and is regular rhythm  I am listening to his S1 and S2- no murmur heard: (**TO DO: FEEL FOR INTERCOSTAL SPACE- starting at top). RIGHT 2ND INTERCOSTAL SPACE LEFT 2ND INTERCOSTAL SPACE LOWER LEFT STERNAL BORDER 4TH SPACE MID-CLAVICULAR 5TH INTERCOSTAL SPACE (USING BELL OF STETHOSCOPE)  S1 AND S2 PRESENT- NO MURMURS O O O o

Upper Extremities

 I am checking his ROM and muscle strength: -

Can you place your hands behind your back raise arms over your head arms out front and cross them bend elbows and then straighten turn palms up to the ceiling, down to the floor Squeeze my hands. Press against my hands: go forward and back  Left: he has full ROM, equal strength bilaterally and strong  Rt: he has full ROM, equal strength bilaterally and strong

 I am checking his brachial pulse and radial pulse  Left: 2 + Normal RADIAL AND BRACHIAL  Right: 2+ NormalRADIAL AND BRACHIAL

Neck Vessels- Lay down Please  I am observing his jugular veins for distention- no distention noted

Abdomen  I am assessing his abdomen- it is rounded, symmetric, no masses, bulging, or pulsations  His umbilicus is midline and inverted

 I am now going to listen to his bowel sounds for normal, hypoactive, or hyperactive bowel sounds    

RUQ RLQ LUQ LLQ

 His bowel sound are active and normal in all 4 quadrants  I am now going to palpate his abdomen starting with light and let me know if you feel tenderness. I am looking for bulges, masses, or tenderness. Then I will assess deeper    

RUQ RLQ LUQ LLQ

 No tenderness at all?  His abdomen is soft with no masses.  I am percussing his abdomen (**TO DO: Place Two fingers on area and tap with two fingers from other hand)  RUQ tympany no dullness noted.  RLQ  LUQ  LLQ

Lower extremities  I am assessing his lower extremities: feel the legs.

 I am looking for symmetrical, color is appropriate, no lesions, hair is evenly distributed, and if edema is present.  I am assessing toenails for any abnormalities  I am assessing his capillary refill - LT- less than 2 sec - RT- less than 2 sec  Skin is warm dry with no edema  I am assessing his pulses  Lt femoral - groin 2+  Rt femoral– groin 2+  Lt popliteal - behind knee 2+  Rt popliteal - behind knee 2+  Lt posterior tibial- ankle 2+  Rt posterior tibial- ankle 2+  Lt dorsal pedis- top of foot 2+  Rt dorsal pedis- top of foot 2+

Musculoskeletal I will now assess the hips, looking for pain, tenderness, and ROM

    

Do you have any pain or tenderness to your hips? Feel hips- I am feeling for crepitus, instability Flex hips: ____ degrees: Lift leg from to the ceiling. Abduction: ____ degrees: Bend at the knee Internal rotation ___ degrees: Bend at knee with foot on bedturn in  External rotation ____ degrees: Bend at the knee out.  Normal range of motion  I am assessing his ankles: Do you have any pain?  No swelling, ulcers, redness, no edema  I am going to assess Ankle strength - Plantar flexion: RT LT- toes down - Dorsiflexion RT LT: toes to your head - Eversion RT LT: toes out - Push, pull against my hands  ROM normal, strong

Ok you can sit up for me now  I am assessing his deep tendon reflexes: I am using a spatula as my prop. Using BOTH ARMS

    

Biceps- feel for tendon. Tap with handle of spatula Triceps- tap above elbow: back of arm Brachioradialis: tap at top of hand, above the thumb Patellar: just below the knee cap Achilles: hold foot in your hand: tap just above the heel

 I am assessing his sensation: Tell me if you can feel this. I am using a pen cap for my prop. Can you close your eyes and tell me if you feel sharp or soft?  Face  Arms  Hands  Legs  Feet - Sensation present

Do you mind standing up for me?

I am going to assess your spine.  Can you touch your toes? - ROM of spine normal and of touching his toes - Palpating his spine: no abnormalities - Any pain? Can you stand up for me? I am assessing further ROM  Can you lean side to side for me and turn left and right, bend back? Full ROM  Any pain?  Can you do a shallow knee bend for me? I am assessing for symmetry & ROM by having him slightly squat  Any pain?  Can you walk across the room using heel to toe?  He has appropriate coordination  Can you walk on your tiptoes? And then on your heels? - He has appropriate coordination  Anything else you feel we need to know? 

Ok thank you for coming in today. If you have any issues please follow-up with your Primary Care Physician...