Skills Test

Patient Name
Sex and Age
SYSTEM
ACTION
General
Introduction and
Survey and
procedures
VS
1.) Observe patient
orientation and
consciousness
2.) Temperature
3.) Pulse Rate and
Respiratory Rate
4.) Blood Pressure
What is/are patient
complaints?
What is height and weight
of patient?
5.) Inspect skin, hair,
and nails on exposed
areas only
HEENT

Head and Face: penlight

1.) Inquire about signs
and symptoms
referable to the
system
2.) Inspection of the
head
3.) Check hair
4.) Check scalp
5.) Check skull and
bone structure
6.) Check face
7.) Check skin
8.) Palpation
9.) Palpate for tender
areas
10.)
Palpate frontal
and maxillary sinus
Eyes: penlight, Snellens
Near Vision Chart
1.) External anatomy
Inspect eyebrows,
eyelids, lacrimal
apparatus,
conjunctiva and
sclerae, cornea, iris
and lens
2.) Pupils
Measure size of
pupils
Check for direct and

REPORT
The patient is a healthy-looking
male/female, alert, well-groomed, and in
good spirit. He/She is oriented to people,
place, and time, with good eye contact.
He/She is medium built,
thin/muscular/frail, weighing _____lbs/kgs
and _____ ft/inch tall.
The patients BP on the right arm is _____
with no auscultatory gap. Pulse rate is
_____ bpm, regular. Respiratory rate is
_____ cpm, not in respiratory distress.
Temperature on left axilla is _____ oC.
Skin/Hair/Nails
The patient complains of _____.
The skull is normocephalic, atraumatic, no
depressions, or any surgical lesions. Hair
is fine/coarse/normal, and with good
moisture.
There are no suspicious
nevi/hyperpigmentation on the face.
[Report about particular skin lesions such
as macule, papule, pustule, and scar
depressions] There are no tenderness
upon palpation of the frontal and
maxillary sinuses. The skin on the face is
generally dry/moist/oily.

There are no unusual prominence and no

periorbital lesions. Eyebrows are
symmetrical with fine/thick/thin hair
distribution and with good moisture.
Lacrimal apparatus are pinkish without
abnormal discharge or exudates. Sclerae
are white, conjunctiva are pink, cornea
has good symmetrical light reflection and
lens are healthy, iris are brown/dark
brown.
Pupils are equally round, reactive to light
and accommodation. They are about

indirect light
reaction
Check for near
reaction
3.) Extraocular muscles
Inspect the 6
cardinal directions of
gaze
Check for nystagmus
Check for lidlag
Check for
convergence

4mm constricting to 2mm in direct light

reaction with consensual constriction.

4.) Visual acuity

5.) Visual fields

There are no particular skin lesions on the

neck, no deformities, and the neck is
supple and symmetrical. There is no
tenderness upon palpation. All 10 lymph
nodes are normally not palpable. Trachea
is midline, thyroid isthmus is palpable,
lobes are not felt/palpable but not
enlarged.

Neck: penlight
1.) Inspection
Check for mass,
deformities,
asymemtry
2.) Palpation
Check for muscle
tendeness
3.) Palpate for lymph
nodes

Eyes can move to all directions of gaze,

there is no nystagmus or lid lag, with
good convergence.
Patient can read at 16 inches what most
people can read at _____ inches in
Snellens Near Vision Chart bilaterally.
Patient has normal visual fields on static
finger wiggle test.

Trachea
1.) Inspection and
palpation of midline
Thyroid Gland
1.) Inspection of the
borders of the
thyroid gland and
assess symmetry.
2.) Palpation
Ears: penlight, otoscope,
tuning fork
1.) Auricle
Inspect for
deformities
Check for ear pain
and discharge
2.) Ear canal and drum
INSPECT discharge,
foreign bodies,
redness swelling,
quality of cerumen
CHECK handle of
malleus, short
process of malleus,

External ears are symmetrical bilaterally,

there is no tenderness on ear tug test and
upon palpation.

There are no lesions along the midline

meatus, no discharge, redness, or
swelling. There is normal presence of
cerumen.
Tympanic membrane with good cone of
light, landmarks are all visible and no
deformities.
Acuity is good to whispered voice, there is

pars flaccida and

pars tensa
3.) Hearing acuity
Whisper test
Weber test
Rinne test
Nose: penlight, otoscope
1.) Check for anterior
and inferior surface
of the nose
2.) Palpate the sinuses
and check for local
tenderness

Cardiovascu
lar

Mouth and throat:

penlight, otoscope
1.) Inspection
Lips, oral mucosa,
gums and teeth,
breath, roof of the
mouth, tongue and
floor of the mouth,
pharynx and tonsils
Tools: penlight, 2 rulers,
stethoscope
1. Inquire about signs
and symptoms
referable to the
system
2. Check the JVP
3. Check the
Abdominojugular
reflex
4. Check the Carotid
arteries for bruits
and grade the pulse
5. Inspection
Check contour
of chest
Check for
visible
precordial
impulse
Check for scars
and lesions
6. Palpation
Check for
heaves, lifts
and thrills
Check for apical
impulse/ PMI
7. Auscultation

no laterality on weber test (weber is

midline), air conduction is greater than
bone conduction.
Ala are symmetrical, no swelling. Inferior
nose have no discharge or exudates, and
there is no particular tenderness upon
palpation.
There are no tenderness upon palpation
of the sinuses. There is good
transillumination of both the maxillary
and frontal sinuses.
Oral mucosa is pink with good dentition.
Pharynx without exudates, breath has no
distinct odor, uvula and tongue are
midline, devoid of any particular lesions.

The JVP is _____ cm above sternal angle at

an elevation of 30o. Carotid upstrokes are
brisk without bruit and graded +2.
The chest has no deformities and no
visible precordial impulse. There are no
scars or any skin lesion on inspection.

There are no heaves or lifts upon

palpation, the PMI is tapping, 7cm from
the midsternal line in the 5th intercoastal
space.
Heart sounds are crisp, with S2 louder
than the S1 at the base, and the S1
louder than the S2 at the apex. There are
no murmurs or extra sounds.

Check S1 and
S2 intensity
Check for heart
sounds in the
base and apex
8. Check for murmurs
Chest and
Lungs

Tools: Stethoscope, ruler

1. Inquire about signs
and symptoms
referable to the
system
2. Inspection
Check for signs
of respiratory
difficulty
Check for the
shape of chest,
deformities and
asymmetry
3. Palpation
Check for
tender areas
Check for chest
expansion
Check for
tactile fremitus
4. Percussion
Percuss
systematically
and compare
symmetry of
percussion
notes
Measure
diaphragmatic
excursion
5. Auscultation
Check breath
sounds
Check
adventitious
sounds
Check voice
transmission

Vascular

Tools: Stethoscope, tape

measure
1. Inquire about signs
and symptoms
referable to the

The patient breathes quietly devoid of

respiratory distress or retractions. Chest
with normal anteroposterior diameter and
symmetrical with normal spinal curvature.

There are no tender areas upon palpation,

chest expansion is good, bilateral, and
symmetrical, with good tactile fremitus.

Posteriorly, scapular line is resonant

bilaterally with dullness on the right lower
thorax. The diaphragm descends 4cms
bilaterally.

Breath sound is vesicular, with no

adventitious breath sounds. Negative for
bronchophony, egophony, and whispered
pectoriloquy.

Upper ex are symmetrical with

circumference of _____ cm, superficial
veins are visible/invisible and
prominent/dilated/distended. Skin supple,
smooth, and with no hyperpigmentation.

2.

3.

Abdominal

4.
1.

2.

3.

4.

5.

system
Upper extremity PE
Inspect for size and
symmetry of
extremities
Observe venous
pattern
Observe color and
texture of skin
Palpate and Grade
Pulses
Lower extremity PE
Inspect for size and
symmetry of
extremities
Observe venous
pattern
Observe color and
texture of skin
Palpate and Grade
Pulses
Note hair distribution
Check for Pitting
Edema
Ankle Brachial PE - not
Inquire about signs
and symptoms
referable to the
system
Inspection of the
abdomen
Check for scars, veins,
lesions
Check for the contour
of the abdomen
Check for visible
peristalsis and
pulsations
Auscultation
Auscultate for bowel
sounds,
Auscultate for bruits
and friction rubs
Percussion
Percuss the entire
abdomen and note
for pattern of the
tympanic sounds
Palpation
Light and deep
palpation
Check for direct and

Brachial, ulnar, and radial pulse are

graded +2 with no bruit.

Lower ex are symmetrical with

circumference of _____ cm, superficial
veins are visible/invisible and
prominent/dilated/distended. Skin supple,
smooth, and with no hyperpigmentation.
Popliteal artery is faintly palpable, dorsalis
pedis and posterior tibial arteries are
palpable and all graded +2 with no bruit.
Hair distribution is scarce with no pitting
edema.

The abdominal area have no prominent

scars or lesion in all 4 quadrants. It is
protuberant/scaphoid/flat/muscular with
no visible peristalsis or pulsations.

It has active bowel sounds of about 5-34

sounds per minute on _____ quadrant with
no bruit or friction rubs.
The abdomen is tympanitic on all 4
quadrants upon percussion.

There are no tenderness upon light and

deep palpation. There are no direct or
indirect tenderness as well.
Kidneys have smooth edges/borders with
no prominent tenderness on palpation.

6.

indirect tenderness
Exams for specific
organs: ( optional)
Kidneys
Spleen
Liver
Gallbladder
Appendix

Spleen is normally not palpable.

Liver span is 6-12cms in the right
midclavicular line and 4-8cms in the
sternal line. Edge is smooth and palpable
1cm below the right coastal margin with
no reported tenderness upon palpation
Gallbladder: murphys test is negative.
Appendix: Rovsings Sign (-), Psoas Sign
(-), Obturator Sign (-), no tenderness on
deep palpation of McBurneys point,
negative cutaneous hyperesthesia on
McBurneys point.