Perusal

(Hand wash)
Introduction
Hello my name is Jacqui and this is my assessor _____. Were here today to do a head
to toe physical assessment. I will be taking your vital signs and assessing various
parts of your body which will involve me having to touch you. You shouldnt feel any
discomfort or pain but if at any point you do, please tell me so I can stop straight
away. You have the right to withdraw at any time and all collected data will be
disposed of appropriately at the end. It should only take about twenty minutes, is it
okay if we proceed?
Now Im going to give you this gown to change into, and if you just pop in here Ill
close the door to give you some privacy and just tell me when youre ready to begin.
General survey
The patients general appearance is normal, if not a bit nervous, but their facial
structure and movements are symmetrical. Their posture is erect and comfortable,
and their gait is balanced, smooth and even and appropriate for age. I havent
detected any weakness or involuntary movement. They are alert and orientated, their
mood matches their affect, and they appear to have good hygiene.
When patient is ready
Im going to start by taking your full name and date of birth.
Vital signs
Im going to start by taking your vital signs. Ill begin with your O2 saturations by
placing this on your finger, with the red light over your nail. While the machine is
doing that, I am going to take your temperature. Im just going to lift your helix to
straighten the canal. Your temperature is _____C, which is within the normal range of
36.4-38C. and your O2 saturationss are _____%, which is also within the normal range
of 95-100%.
Next Ill take your pulse and respiration. Each is going to take a full minute so please
be patient. Your pulse is _____ beats per minutes which is within the normal range of
60-100 bpm - bradycardia is less than 60 bpm and tachycardia is more than 100 bpm.
And your respiration is at _____ breaths per minutes which is within the normal range
of 10-20 breath per minute. Also your breathing is relaxed, automatic, quiet and
regular.
Now Ill be taking your blood pressure. Is there any arm that I cant use? Do you have a
preferred arm? So firstly Ill find your brachial pulse and align the cuff over it. Now Im
going to palpate the radial pulse, and inflate the cuff until I can no longer feel it. I lost
the pulse at _____ mm of mercury so I will inflate it 30 mmHg above that to cover the
auscultatory gap and then auscultate the brachial artery to find the blood pressure.
Your blood pressure is ___/___ mmHg, which is within the normal ranges of 90120mmHg for systolic and 60-80mmHg for diastolic. Normally stated as 120/60mmHg.

Finally for vital signs I want you to rate your pain on a scale of 1 to 10 one being no
pain and ten being the worst pain that youve experienced? And what about when you
walked into the room today?
Sensory and neurological assessment
Glasgow coma scale
Now Im going to give you a score on the Glasgow coma scale. Can you tell me where
you are? Do you know todays date? The patients
eyes are opening spontaneously (4)
orientated to time, place and person, which you demonstrated now and also at
the start by telling me your name and date of birth (5)
obeying commands, which you demonstrated at the start of this examination by
taking and putting on the gown (6)
That gives you a score of fifteen, which is the best response.
Visual Reflexes
Now Im going to test your visual reflexes, specifically your cranial nerves two and
three, the optic and oculomotor nerves respectively. Firstly, at rest your pupils have a
diameter of ____mm, which is within the normal range of 3-5mm. Im going to shine
this light into both of your eyes twice, normally when one would perform this
procedure they would dim the lights for a better effect. Please look straight ahead at a
fixed point behind me. The pupils are equally round and reactive to light. There is both
a direct and consensual reaction the constriction in the eye that the light is shining
into is the direct reaction and the other pupil reacting at the same time is the
consensual reaction. This is a normal response because of the light crossing the optic
nerve in the brain.
Peripheral vascular assessment
I will now do a peripheral vascular assessment. Im going to observe both your upper
and lower limbs, is that okay with you? Ill begin with your hands. So both your hands
are warm and pink in colour. Can you feel me touching squeezing your hands? Okay,
so you have full sensation in both hands. Now can you please press down against my
resistance? (above, below) And you have full movement and power in both hands.
Now Im going to squeeze your fingertips to observe capillary refill. It was fast and
under two seconds which is considered normal. The colour of the nail beds is pink and
healthy. Now Im going to check the pulses in your arms. Your radial/brachial pulses
are:
Present and bilaterally equal in rate, rhythm, force and elasticity.
I would rate them:
0: absent
1+: diminished
2+: normal
3+: full pulse
Glasgow coma scale chart
eyes opening spontaneously (4)
orientated to time, place and person, which you also demonstrated at the start
by helping me fill out the forms
obeying commands, which you demonstrated at the start of this examination by
taking and putting on the gown (6)

Nail bed angles

Now can you please put your fingers like this and hold it up for me? Thank you. That
was to check your nail bed angle, and yours looks to be about 160, which is a
normal finding.
Feet
Your feet are both warm and pink in colour. Can you feel me squeezing your feet?
Okay so you have full sensation in your feet. Now can you please push against my
resistance? (above, below) And you also have full movement and power in both feet.
Now Im going to squeeze your toes to observe capillary refill. It was fast and under
two seconds which is considered normal. The colour of the nail beds is pink and
healthy. Now Im going to check the pulses in your feet, and then one in your leg. Your
dorsalis pedis/posterior tibial are:
Present and bilaterally equal in rate, rhythm, force and elasticity
I would rate them:
0: absent
1+: diminished
2+: normal
3+: full pulse
I cant seem to find your popliteal pulse but this is normal for a healthy adult.
Respiratory Assessment
I will now do a respiratory assessment on you. This will require some more touching
and exposure of your back, is that okay? Okay, can you please lean forward and
expose your back? Is it okay if I undo your gown? Could you please lean your head
forward. I saw before tha your clavicles are symmetrical and there doesnt seem to be
any wastage of muscle, anteriorly or posteriorly. The spinal processes appear to be in
a straight line and the scapulae are symmetrical. There are no abnormal legions,
moles or scars. The temperature and colour are normal and there are no signs of
barrel chesting because the anterior and posterior to lateral ratio is about 2 to 1.
Im now going to palpate your back. I cant feel any abnormal lumps and there doesnt
seem to be any pain.
Im now going to percuss the intercostal spaces and compare each side I will also be
percussing laterally, under your arm. Is that okay? This test makes sure there are no
abnormal densities or too much air in the lungs. Could you please cross your arms
across your body, grabbing the opposite shoulder if you can. When percussing I heard
low pitched hollow sounds, indicative of resonance. This is a normal finding.
Now Im going to auscultate across your lung fields in the same places that I just
percussed. For this can you please breathe deeply in and out through your mouth, and
if you feel dizzy at any time just let me know and we can stop right away. Breathe in.
Over the major bronchi, between the scapulae, Im hearing bronchovesicular
sounds which are of a moderate pitch and volume. And below I'm hearing
vesicular sounds, which are found over the peripheral lung fields where the air flows
through smaller bronchioles and alveoli. These sounds are soft, low pitched sounds
similar to rustling leaves and are heard more on inhalation. This is all normal.
Cardiac Systems

Now Ill be checking your heart sounds, which requires the exposure of the top of your
chest. Is that okay? Ill only be auscultating two of your valves today but there are four
in total. First is the aortic valve, which you listen to right of the sternal border in the
second intercostal space, which you can usually find using the angle of Louis. I cant
hear any mummers which is good. Secondly, is the pulmonic valve, which is also in
the second intercostal space but left of the sternal border. I cant hear any mummers
over this side either which is good. These two valves provide the S2 sounds, which are
loudest at the base of the heart and indicate the closure of these semilunar valves
and the beginning of diastole. The other two valves are not being auscultated today
but they are the tricuspid and the mitral valves. These sounds are both located in the
fifth intercostal space. The tricuspid is left of the sternal border and the mitral is left
mid-clavicular line. They are the S1 sounds, which are the loudest at the apex of the
heart and indicate the closure of these atrioventricular valves and the start of systole.
I am

now going to palpate your carotid artery. I would rate it:

0: absent
1+: diminished
2+: normal
3+: full pulse
Digestive System

I am now going to assess your digestive system. This will require the exposure of your
abdomen, is that alright? So the contour is flat and there are no abonormal legions,
moles or scars. And the umbilicus is in/everted.
Now I will auscultate the abdomen. The reason that I'm auscultating first is because
palpating and percussing can interrupt the bowels peristalsis and give a false
interpretation of the bowels sounds. I will start in the right lower quadrant, at the
ileocecal valve where the sounds are often the loudest, and I will move around in a
rainbow or clockwise direction. I am only going to briefly listen but normally one would
listen for 3-5 minutes and expect to hear 5-30 irregular cascading gurgling sounds.
I am now going to palpate these same areas. There doesnt seem to be any abnormal
lumps or any sign of pain.
Conclusion
That concludes this examination. Your overall findings prove that you are a healthy
young adult. Thank you for your time. Ill just step out and give you some time to get
changed.