Physical Examination

VIII. Physical Examination

Vital Signs:

Specify limb and position of patient for Blood pressure

General Appearance:

Weight (Kg). 

Height (Inches or cm) 

BMI (weight in Kg/Height in Meter2)

Activity: 

Level of Conscious Personal hygiene: Good / Avenge /Poor

Presence of pallor, icterus, cyanosis, clubbing:

Subjective data                                          Objective data

Level of consciousness and Mental status:

□ Assess vision and hearing before you decide that patient has mental problem.

Level of consciousness (GCS):

• Orientation:

• Speech and Language:

• Memory (Immediate, Recent & Remote):

• Concentration:

• Calculation:

• Abstract reasoning & Judgement:

• Thought process and perception:

• Behaviour and affect:

• Mood, feelings and expression:

• Dress and grooming:

• Hygiene:

• Facial expression:

• Visual, perceptual and constructional ability:

Skin, Hair, and Nails:

Skin 

Inspection

Skin colour (e.g.pigmentation / pallor/ cyanosis/ jaundice/Acanthosis):

Colour variation:

Any codor from skin:

• Skin integrity (intact/bound/bed sore, etc)

• Presence of lesion:

Palpation:

• Texture (smooth/even/rough/flaky/dry):

• Thickness

• Moisture:

• Temperature (warm/cold):

• Skin mobility and turgor:

• Presence of edema:

Hair

Inspection

• Distribution of hair over body, scalp, axilla, and pubic area:

Nails

Inspection

• Grooming and cleanliness:

• Colour & marking:

• Shape of nails:

Palpation

• Texture (hard/smooth/immobile):

Head

Inspection and palpation

Hair (distribution/colour/clean/dry etc.):

Any abrasions/wound Any device:

Size, shape and configuration:

Any involuntary movements:

Palpate for consistency (smooth/lesion/lump):

Face

Inspection and palpation

Shape, movements, expression and skin:

On palpation of temporal artery:

Palpation of temporomandibular joint(TMJ):

Neck

Inspection

Position, symmetry, lump or mass:

Movements of neck structure Cervical vertebrae:

Range of motion (flexion, extension, lateral abduction and rotation):

Palpation .

Trachea (position):

Head and Neck:

Lymph node:

Auscultation

For Sound (no bruit / swishing):

Eyes (Vision):

Test distant visual acuity: (Patient are asked to distinguish with or without corrective

glasses/lenses Snellen chart at 20 feet distance):

Test near visual acuitv: (Patient are asked tn distinguish with or without corrective classes/

lenses Snellen chart or newspaper at 14 inches distance

Position test: to asses eye muscle strength and cranial nerve function (eye movements in six direction):

Inspection of external eye structure:

Eyelids and eyelashes:

Lid margin (ptosis/retracted lid margin/etc):

Ability to close eyelids:

Any redness, swelling, discharge, or lesions:

Position and alignment of eyeball in the socket:

Bulbar conjunctiva and sclera:

Lacrimal apparatus:

Cornea and Lens:

Iris and Pupil:

Pupillary reaction to light:-

Accommodation test of pupil:

Internal eye structure (using ophthalmoscope) 

Red reflex (round, regular border/black spots/etc.):

Optic disc:

Any foreign body, wound, laceration, edema:

Ears (Hearing):

External ear structure Inspection

• Use of ear/ hearing aids:

• Appearance of Auricle, tragus and lobule (size/shape/position/lesions/colour/discharge/etc):

Palpation

• Auricle and mastoid process (pain/tenderness): Internal ear structure

Inspection

• Auditory canal (colour/earwax/any nodule):

• Tympanic membrane/eardrum (Colour/shape/consistency etc):

Hearing and equilibrium tests

• Whisper test:

• Weber’s test:

• Rinnetest:

• Romberg test:

Mouth, Throat, Nose and Sinuses :

Mouth

Inspection and palpation

• Lips (consistency/colour):

• Teeth (No. ofteeth/colour/condition):

• Gums (colour/consistency/lesion/mass, etc):

• Buccal mucosa (colour/consistency/lesion/mass, etc):

• Tongue (colour/moisture/size/texture, etc):

• Ventral surface of Tongue (colour/lesion, etc):

• "Wharton’s ducts (colour/swelling or pain, etc):

• Sides of tongue:

Strength of tongue (CN-IX & X):

Anterior tongues’ ability to test:

• Hard and soft palates and Uvula (colour/consistency/lesion/etc):

• Odour from mouth (any foul odor):

• Uvula(position/colour):

• Tonsils (colour/size/any lesion or exudate, etc):

• Posterior pharyngeal wall (colour/any lesion or exudate, etc):

Sinuses

PalPation

• Frontal and maxillary (tendemess/any crepitus/pain):

• Percussion (tenderness):

• Transillumination (presence or absence of red glow):

Respiratory system:

General inspection

• Inspect for nasal flaring and pursed lip breathing

• Observe colour of face, lips and chest:

• Inspect colour and shape of nails:

• Patient is on: room air / oxygen / BiPAP / Ventilator If on 0, support: flow rate: Mode:

• Endotracheal tube: present / absent; size:

• Respiratory patterns:

Posterior thorax Inspection

• Scapula' and spinous processes (symmetry/shape, etc):

• Use of accessory muscles (trapezius / shoulder):

• Sitting position:

Palpation

• Sensation and tenderness (warm/cold/sensation/pain /lesion/mass etc):

• Crepitus:

• Tactile fremitus (equal bilaterally):

• Assess chest expansion: Percussion

• Tone (resonance/hyperresonance):

• Diaphragmatic excursion (normally 3-5cin):

Auscultation:

Breathing sound heard (normal /abnormal-e.g. crackles/rhonchi/wheezes/pleural friction rub/ stridor/any other):

• Breathing sound at:

♦ Vesicular:

♦ Bronchial:

♦ Bronchovesicular:

♦ Adventitious sound: (Present/Absent)

Anterior thorax Inspection

• Shape and configuration (symmetry/shape, etc):

• Ratio of Anterioposterior verses transverse diameter (normal 1:2)

• Position of sternum:

• Sternal retraction:

• Slope of the ribs:

Quality and pattern of respiration: • Intercostal space (retraction/bulging):

• Use of accessory muscles (stemomastoid /rectus abdominis):

Palpation

• Sensation and tenderness (warm/cold/sensation/pain /lesion/mass etc):

Crepitus:_

• Tactile fremitus

(equal bilaterally):

• Assess chest expansion:

Percussion

• Tone (resonance/hyperresonance):

• Diaphragmatic excursion (normally 3-5cm):

Auscultation:

• Breathing sound heard (normal /abnormal-e.g. crackles/rhonchi/wheezes/pleural friction

rub/stridor/any other):

• Breathing sound at:

♦ Vesicular:

♦ Bronchial:

Bronchovesicular:

Adventitious sound: (Present/Absent)

Female breast

Inspection

• Size and symmetry:

• Colour and texture:

Superficial venous pattem:

Areola (colour/size/shape/texture):

• Nipples (size/direction/discharge/lesion/etc.):

• Retraction or dimpling:_____________

Male breast, areolas, nipple and axillas:

Circulatory system (Cardio-vascular):

Palpation

• Tenderness & temperature:________

• Mass (sizc/location/shape/etc):_____

• Nipple (discharge):______________

• Scar (mastectomy/lumpectomy): Axilla

Inspection & Palpation

• Mass/tenderness/lesion/rash/etc:

Inspection & Palpation

• Any swell ing/nodules/discharge/etc. :

Neck

Inspection

• Jugular venous pulses:

Auscultation and palpation

• Auscultate Carotid artery (bruit/blowing/swishing sound):

• Palpate Carotid artery (elasticity / thrillness):

Heart (Precordium)

Inspection

• Pulsation (visible location):

Palpation

Apical impulses (present/absent/location):

Any pulsation or vibrations present in the area of apex, left sternal border or base

Auscultation

• Rate (per minute):

• SI (lub) and S2 (dubb) sound:

___regular/irregular rhythm

• Extra heart sound (S3.S4):

• Murmur sound:_____

Arms Inspection

Colour, size, Venous pattern, and edema:

Circulatory system

Palpation

• Fingers, hands, arm, and warmness:

Capillary refill time:

• Radial pulse (elasticity and strength):

• Ulnar pulses (present/absent):

• Brachial pulse (strength):

• Allen test:

Legs

Inspection, Palpation and Auscultation

Distribution of hairs:

Any lesion or ulcer:

Edema with characteristics :

• Varicosities and thrombophlebitis:

Gastrointestinal System:

Abdomen

Inspection

• Colour of skin:

• Vascularity of the skin:

• Presence of scars:

Assess for lesion and rashes:

• Observe for Umbilicus for skin colour, location and contour:

• Abdominal contour (flat/rounded/scaphoid):

• Symmetry:

• Aortic pulsation:

• Peristaltic waves:

• Observable mass:

Auscultation

NOTE: in abdominal examination, auscultation is done before percussion and palpation as these latter steps may alter the bowel sound.

• Bowel sound (intensity, pitch & frequency):

• Vascular sound (presence or absent of bruit sound):

• Venous hum over epigastric and umbilical areas:

Friction rub over the spleen and liver:

Percussion

Percuss for tone (tympany & dull sound at different location):

• The span or height of the liver:

Spleen:

Blunt percussion over the LIVER and KIDNEY:

Palpation

• Light palpation to find tenderness and muscular resistance:

Deep palpation at all 4 quadrants to delineate abdominal organs and detect aubtle mass es:

Assess for masses (in all quadrants):

Umbilicus and surrounding:

Liver(usually not palpable):

Spleen (rarelv.palpable at left costal margin):

Kidney (usually not palpable):

Urinary bladder:

Special test; e.g.,

Ascites (shifting dullness, fluid wave test)

Appendicitis (rebound tenderness, psoas sign, obturator sign, hypersensitivity test):

Musculoskeletal system

Gait

Inspection

• Patient’s ability to walk and move around:

• foot position, posture and arm swing during walk:

Temporomandibular joint: Inspection and palpation

• Distance between upper and lower teeths when patient opens mouth:

any pain, swelling etc :

Lateral movements of J aw:

inches;

Sternoclavicular Joint: Inspection and palpation

• Location, colour, swelling, mass and tenderness:

Cervical, thoracic and Lumbar vertebra: Inspection and palpation

• Symmetry, curves/shapes and difference in shoulders height:

• Movements of cervical spine: '

✓ Flexion and hyperextension:

✓ Lateral bending:

✓ Rotation:

• Movements of thoracic and lumbar spine:

✓ Flexion and extension:

✓ Lateral bending:

✓ Rotation:

• Measure leg length:

• Straight leg test:

Shoulder, and Arm: Inspection and palpation

• Assess for

• Movements

✓ Flexion and hyperextension:

Adduction and abduction:

symmetry, colour; swelling and masses:

✓

✓ External and internal Rotation:

Elbows: Inspection and palpation

• Assess size, shape, deformities, redness, or swelling:

• Movements:

> Flexion and extension:

> Supination and Pronation:

> External and internal Rotation:

Wrist: Inspection and palpation

• Assess size, shape, symmetry, colour, swelling:

• Presence of tenderness and nodules:

• Any tenderness in anatomical snuffbox:

• Movements:

> Flexion and extension:

> Radial and ulnar deviation:

• Special test: examples:

• Carpal tunnel syndrome

> Test for Thumb weakness:

Hands and fingers: Inspection and palpation

• Assess size, shape, symmetry, colour, swelling:

Palpate for tenderness, swelling, bony prominence, nodules or crepitus:

Movements:

> Abduction and adduction:

> Flexion and hyperextension: > Thumb away from fingers

> Thumb touching base of small finger: 

Hips: Inspection and palpation

• Assess patient’s ability to stand, symmetry:

• Movements:

> Abduction and adduction:

> Flexion and hyperextension:

> Internal and external hip rotation 

Knees: Inspection and palpation

• Assess size, shape, symmetry, swelling, deformities, and alignment:

• On palpation knee (tenderness, warmth, consistency, nodule):

• Movements:

> Flexion and hyperextension:

• Special test:

• Ballottement test:

• McMurray’s test:

Ankles and Feet: Inspection and palpation

• Assess patient in sitting, standing and walking for position, alignment, shape and skin of

- toe and feet:

• Palpation of ankles and feet (tenderness, heat, swelling or nodule, pain):

• Metatarsophalangeal Joint (pain/tendemess):

• Movements:

> Dorsiflexion and plantarflexion of foot & ankle: 

> Eversion and inversion:

> Abduction and adduction:

> Flexion and extension:

Test for meningeal irritation:

Brudzinski’s sign:

Kemig’s sign:

Male Genitalia

Penis

Inspection

• Urinary catheter present / absent:

Inspect the base part of penis, pubic hairs, skin of the shaft, foreskin, glans:

Palpation

• Palpate the shaft for tenderness, pain, discharge, etc:

Scrotum Inspection

Inspect the size, shape, position and skin of scrotum:

Palpation

• Palpate for size, shape, consistency, masses, swelling, and tenderness:

Inguinal area Inspection

• Inspect the Inguinal and femoral areas for any bulge:

Palpation

• Palpate on both side of Inguinal area for lymph node, masses or bulging, femoral hernia:

Female Genitalia

External genitalia

Inspection

• Urinary catheter present / absent:

• Assess the mons pubis, inguinal lymph, labia majora and perineum:

• Inspect the labia minora, clitoris, urethral meatus, and vaginal opening:

Palpation

• Bartholin’s gland (swelling, pain, discharge):

• Urethra (discharge, tenderness):___________

Internal genitalia

Inspection

• Observe the size and angle of vaginal opening:

• Assess vaginal musculature:________________

Inspection of cervix (smootheness, colour):

Assess the vagina (redness, lesion, colour, discharge): Bimanual examination (tenderness, lesions, pain):____

Anus and rectum

Anus and rectum Inspection

• Inspect anal opening area for lump, ulcer, lesion, rashes, redness, fissures, thickness of skin:

• Assess Valsalva’s maneuver:

• Assess sacrococcygeal area for swelling, redness, dimpling or hair, etc:.

Palpation

• Anus: any sphincter tightness, bleeding, pain, etc.

• Rectum: presence of smoothness, tenderness, nodules, irregularities, etc.

• Prostate gland: (normally nontender and rubbery):

Inspect stool, if available: