NURS 6512: Physical Examination Reference Sheet

NURS 6512: Physical Examination Reference Sheet

NURS 6512 – Advanced Health Assessment & Diagnostic Reasoning

Purpose: To guide students in documenting objective findings only during the physical

examination.

REMINDER: PHYSICAL EXAM = OBJECTIVE DATA ONLY

This section should include only what you observe, measure, or assess — not what the patient

reports. Do NOT include subjective statements or history.

✅ Correct (Objective): “Lungs clear to auscultation bilaterally; no wheezes, rales, or rhonchi.”

❌ Incorrect (Subjective): “Patient reports shortness of breath and chest tightness.”

GENERAL FORMAT FOR PHYSICAL EXAM DOCUMENTATION

• General: Appearance, distress, hygiene, orientation

• Skin: Color, temperature, turgor, lesions, rashes

• Head: Normocephalic, atraumatic

• Eyes: PERRLA, EOMI, conjunctiva clear

• Ears: TM intact, no erythema or effusion

• Nose: Mucosa pink, septum midline, no discharge

• Mouth/Throat: Mucosa moist, no erythema or exudate

• Neck: Supple, no lymphadenopathy, thyroid non-enlarged

• Cardiac: RRR, no murmurs, rubs, or gallops

• Lungs: CTA bilaterally, no wheezes, rales, or rhonchi

• Abdomen: Contour, bowel sounds, tenderness, organomegaly

• GU: External genitalia, discharge, lesions, CVA tenderness (as indicated)

• Musculoskeletal: ROM, strength, gait, deformities, tenderness

• Lower Extremities: Edema, pulses, color, warmth, capillary refill, sensation

• Neuro: CN II–XII grossly intact, strength and sensation symmetrical

Chief Complaint, Must-Not-Miss Diagnoses, and Systems to Examine

Identify high-priority conditions and focus your exam to rule them out.

Chief Complaint Must-Not-Miss Diagnoses Systems to Examine

Cough or Shortness of

Breath

Pneumonia, Pulmonary

embolism, Myocardial

infarction, Heart failure,

Pneumothorax

Respiratory, Cardiac, ENT,

Skin (cyanosis), Lower

Extremities (edema/DVT

signs)

Abdominal Pain Appendicitis, Bowel

obstruction, Perforated

Abdomen, GU, Cardiac,

Respiratory, Skin

ulcer, Ectopic pregnancy,

Cholecystitis, Pancreatitis

(jaundice), Neuro (pain

localization)

Headache Subarachnoid hemorrhage,

Meningitis, Temporal

arteritis, Intracranial mass,

Hypertensive emergency,

CVA (stroke)

Neuro, HEENT, Neck, Eyes

(fundoscopic), Cardiac (BP),

Skin (rash/meningitis)

Back Pain Cauda equina syndrome,

Epidural abscess, Spinal

fracture, Pyelonephritis,

Abdominal aortic aneurysm

(AAA)

Musculoskeletal, Neuro,

Abdomen, GU (CVA

tenderness), Skin

(infection)

UTI Symptoms Pyelonephritis, Urosepsis,

Pregnancy, Obstructive

uropathy

Abdomen, GU, CVA

tenderness, Skin (fever

signs), Neuro (confusion in

elderly)

Sore Throat Peritonsillar abscess,

Epiglottitis, Mononucleosis,

Streptococcal pharyngitis

HEENT, Lymphatic, Neck,

Cardiac, Respiratory

(airway), Skin

(rash/scarlatina)

Rash Cellulitis, Meningococcemia,

Stevens-Johnson syndrome,

Drug reaction, Anaphylaxis

Skin, Lymphatic, HEENT

(mucosal lesions),

Respiratory (distress),

Cardiac (shock signs)

Extremity/Joint Pain DVT, Septic joint, Fracture,

Cellulitis, Compartment

syndrome

Musculoskeletal, Neuro,

Lower Extremities (pulses,

edema, warmth, sensation),

Skin

DOCUMENTATION TIP

• Use head-to-toe format only for comprehensive exams (annuals, new patient, baseline).

• Use focused format for problem-based visits.

• Objective findings should align with your assessment and must-not-miss differential diagnoses.