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Assessment Checklist Cheat Sheet by

General Assessment
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Vital Signs

Height
Weight
Pulse (60-100)
Respir­ations (12-20)
Temper­ature (97.8-­99.1)
Blood Pressure (120-1­39/­80-89)
Pain (scale of 0-10)

Integu­mentary

Inspect: color, moisture, hair, rashes, lesions, pallor, edema
Palpate: temper­ature, turgor, lesions, edema, texture

Scalp

Inspect: shape, symmetry
Palpate: tender­ness, deformity

Nails

Inspect: shape, color
Capillary refill (< 3 sec)

Head

Inspect: symmetry, shape, size, uniformity
 

Neck

Inspect: symmetry, lesions, scars
Palpate: tender­ness, lymph nodes, thyroid gland, TMG

Eyes

Inspect: interior and exterior, visual fields, acuity, reflexes

Ears

Inspect: color, shape, symmetry, interior inspection
Palpate: tender­ness, deformity

Nose

Inspect: shape, symmetry, interior inspection
Palpate: frontal sinus, maxillary sinuses

Mouth and Throat

Inspect: interior and exterior
 

Thorax and Lungs (anterior and posterior)

Inspec­tion: respir­ation quality, symmetry, deformity, tracheal location
Palpation: tender­ness, fremitus, chest expansion
Percus­sion: percussive tones, diaphr­agmatic excursion
Auscul­tation: breath sounds and quality

Heart and Great Vessels

Inspec­tion: jugular venous pulse
Palpate: pulses, PMI
Auscul­tate: heart sounds (S1, S2)

Peripheral Vascular System

Inspect: color, edema
Palpate: temper­ature, edema

Abdomen

Inspect: discom­fort, unifor­mity, color, symmetry, scars, hernia, perist­alsis, pulsations
Auscul­tate: bowel sounds, bruits
Percus­sion: four quadrants, liver, spleen, renal tenderness
Palpation: light to deep, liver, spleen, aorta, rebound tender­ness, fluid wave
 

Muscul­osk­eletal

Inspec­tion: asymmetry, deformity, atrophy
Palpation: major joints, tender­ness, deformity, ROM

Neurol­ogical

Inspect: mental status, cranial nerves, coordi­nation, movement, senses
Palpate: motor strength, muscle tone, reflexes, senses

Genito­urinary

Inspect: general appear­ance, lesions, scars
Palpate: breast exam, testicular exam, prostate exam, vaginal exam, pap smear

Lymphatic

Palpate: assess lymph node locations

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