physical examination guide

7/31/2019 Physical Examination Guide

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PHYSICAL EXAMINATION GUIDELINE

I. General InformationName of Client: __________________________________________________________ Age: ________ Sex: ________Unit/Ward: ______________ Bed No.: _________ Examiner: _______________________________________________Home Addres: ____________________________________________________________________________________

II. Vital Signs and Anthropometric MeasurementsT:___________________ oral axillary rectal tympanic

BP:__________________ sitting lying standingPR:_______________/min RHYTHM: regular irregularVOLUME: absent thready/weak bounding normal

HR:_______________/min regular irregularRR:_______________/min DEPTH: normal deep shallow

RHYTHM: regular irregularQUALITY: effortless labored use of acce.muscles

WEIGHT: __________kg HEIGHT: __________cmBMI: ______________kg/m2 MUAC: ___________ cmWAIST CIRC: _______cm HIP CIRC: _________cmWAIST-HIP RATIO: _____________

III. General SurveyBuild: endomorph mesomorph ectomorph

Posture and Gait: relaxed/erect coordinated uncoordinated staggering shuffling stumbling unable to walk alone walks with assistive devices

Hygiene: clean/neat unkempt halitosis ( ammonia-odor acetone-odor foul-odor) bromhidrosis

Nutrition: well-nourished obese cachexicGeneral Appearance: relaxed signs of distress ( pain,

cardio-respiratory anxiety)Emotional State: calm worried restless tense

others: ______________________________Development: well fairly poorly looks accdg to age

Looks younger older

Level of Consciousness: conscious lethargic obtunded stuporous comatoseCoherence: coherent incoherentOrientation: oriented to disoriented to

( time person place)

IV. IntegumentGeneral Color: normal pallor cyanosis jaundice

erythema vitiligoTexture: smooth rough others: _____________________Temperature: warm cool others: ___________________Turgor: good fair poorMoisture: normal dry wet/clammy oilyLesions:PRIMARY: ecchymosis macule patch papule

plaque nodule tumor vesicle bulla pustule cyst wheal SECONDARY: atrophy erosion lichenification scales crust ulcer fissure scarkeloid excoriation

Edema: pitting non-pitting (GRADING: ____________)

USE TO LOCATEPAIN (red), LESIONS (blue), EDEMA (green)

USE TO GAUGE PAIN

V. NailsColor: pink pallor cyanosisNail Plate: convex spoon-shaped/koilonychia clubbingCapillary Refill:______ seconds normal delayedTexture: smooth thick thin beaus linesInflammation: negative positive

(characteristics:____________________________________)Hygiene: clean dirty

VI. HeadConfiguration: normocephalic smooth contour

others: ______________________________________ nodules masses depressions

Fontanelles: closed open sunken bulgingFacial Features: symmetric slightly symmetric

asymmetric exophthalmos moon-faced myxedema

Facial movements: symmetric asymmetric involuntary

facial movements

VII. NeckTrachea: midline deviated to ( right left)Lymph Nodes: nonpalpable palpable enlarged tenderThyroid: nonpalpable enlargedRange of Motion: normal rigidCarotid Pulse:____________/min symmetric asymmetric

RHYTHM: regular irregularVOLUME: absent thready/weak bounding normal

NVE:____________

Masses: present absentTonic Neck Reflex: present absent

EDEMA GRADING1+ = 2mm deep2+ = 4mm deep3+ = 6mm deep4+ = 8mm dee

BMI I nterpretation30 obese (>40 extremely obese)


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VIII. EyesLids: symmetrical asymmetrical edema/swelling (R L)

ptosis (R L)Periorbital Region: edema sunken discolorationEyelashes: equally distributed curled outward

turned inwardEyebrows: evenly distributed loss of hair symmetrical

asymmetrical skin intact scaling flaking equalmovement unequal movement

Conjunctiva: pinkish pale red extremely pale extremely red lesion dischargeSclera: anicteric subicteric icteric hemorrhagesLacrimal sac and NL duct: non-tender tenderCornea: transparent shiny smooth arcus senilis

(+) sensitivity (-) sensitivityIris: transparent dicoloration opacity cloudinessPupils:R:_____mm L:_____mm equal unequalReaction to Light:R brisk sluggish fixed

L brisk sluggish fixedReaction to Accomodation: equal unequalPeripheral Vision: intact smaller than normal half-visionExtraocular Muscle Test: intact non-intact nystagmusVisual Acuity: grossly normal R:____/____ L:____/____

wears eyeglasses/contact lenses (grade: R:___ L:___)

IX. EarsAuricles: symmetrical asymmetrical aligned with outer

canthus of the eye low-set earsColor: same as facial skin pallor cyanosisTexture/Elasticity/Tenderness: mobile firm non-tender

tender pinna recoils after foldedGross Abnormalities: _________________________________External Canal/Middle Ear: impactedcerumen discharge

( foul smelling serous purulent mucoid)

Gross Hearing: symmetrical deafness (R L) with hearing devices: ___________________________Rinnes Test: R ______ L ______Webers Test: lateralization (R L)

Startle reflex: present absentSecondary Skin Lesions:Atrophy: dry, paperlike, wrinkled skin surfaceErosion: moist, shallow depression, epidermis onlyLichenification: rough, thickened, hardened areaScales: shedding flakes of greasy, keratinized tissueCrust: dry blood, serum, or pus left on the surfaceUlcer: deep, irregularly-shaped, extending to dermis or subQFissure: linear crack with sharp edgesScar: flat, irregular area of connective tissue after wound healingKeloid: elevated, irregular, darkened area of excess scar tissue

Excoriation: linear erosion

X. NoseNasolabial Fold: symmetrical shallow (R L)Septum: midline deviated (R L) perforatedMucosa: pinkish pallor cyanosis redness

discharge ( bloody serous purulent mucoid)Patency: both patent obtructed (R L)

Masses/LesionsSinuses: tender non-tenderGross Smelling: symmetrical olfactory deficiency (R L)

XI. MouthLips: pinkish pallor cyanosis dry/crack lesionsMucosa: pinkish pallor cyanosis moist dry lesionsTongue: midline deviated to (R L) atrophy

fasciculation lesionsTeeth: complete incomplete braces retainers

Caries (red), Missing (green), Dentures (blue)Gums: pinkish pale bleeding tender nontender

Speech: intact slurred aphasic others: _____________ Gag Reflex: present absentRooting Reflex: present absentSucking Reflex: present absentExtrusion Reflex: present absent

bronchovesicular over ____________ bronchial over _____________

Adventitious Breath Sound: absent fine crackles coarse crackles wheezes rhonchi stridor

USE TO LOCATECARIES (red), MISSING TEETH (green), DENTURES (blue)

XII. Chest and LungsInspiration:Expiration ratio:____ : ____Shape:APL ratio: ____ : ____ barrel funnel pigeonChest Expansion: symmetrical decreased/lag (R L)Tactile Fremitus: symmetrical decreased or increased

@ (R L) lung fieldPercussion: resonant dull tympanitic hyrresonantBreath Sounds: vesicularover ____________

Sound Character Indication

Vesicular Insp. > Exp. Normal

Bronchovesicular Insp. = Exp. NormalBronchial Exp. > Insp. Normal

Fine Crackles* Soft, high-pitched (5-10msec)

Pneumonia,fibrosis, earlyCHF, bronchitis,bronchiectasisCoarse Crackles* Louder, lower in

pitch (20-30msec)

Wheezes High-pitched;have hissing orshrill quality

Narrowed airwaysas in asthma,COPD, bronchitis

Rhonchi Low-pitched;

have a snoringquality

Secretions in large

airways

* crackles is sometimes called rales

Primary Skin Lesions:Macule: flat, 1mm to 1cmPatch: flat, >1 cmPapule: circumscribed, elevated, 1cmNodule: elevated, deeper than papule, 0.5 2cmTumor: elevated, deeper, may be irregular in shape, >2cmVesicle: circumscribed, with serous fluid, 0.5cmPustule: vesicle o bulla filled with pusCyst: >1cm, fluid-filled, deeper than vesicle and bullaWheal: reddened, irregular in shape


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XIII. HeartPrecordial Area: flat bulging

normodynamic hyperdynamic tenderness PMI at ____________________________________ pulsation

displaced ( laterally lower) heave thrillAortic area at _______________________________________

pulsation heave thrillPulmonic area at _____________________________________

pulsation heave thrill

Tricuspid area at _____________________________________ pulsation heave thrillApical area at _______________________________________

pulsation heave thrillHeart Sounds: distinct faint

S1 _____ S2 at base S1 _____ S2 at apexExtra heart sounds: S3 S4Murmurs: absent present (GRADE: _________)

Best heard at ____________________________________Jugular Vein: not visible distendedJugular Venous Pressure*:____cm elevated not elevated

XIV. Breast and AxillaeSize: symmetrical asymmetricalAppearance: same as color of abdomen or back

discoloration striae dimpling/retraction hypervascularization swelling edema

Areola: round oval symmetrical asymmetricalNipples: round everted inverted symmetrical size

asymmetreical size discharge: ___________________Lymph Nodes: palpable non-palpable

Breast tissue: non-tender tender masses nodules discharge: ____________________________________

XVI. Ano-GenitalFEMALE:Pubic Hair: kinky inverse triangle scant extended toabdomen parasites lesionsLabia: symmetrical asymmetrical pinkish discoloration Orifice: same color as surrounding tissue discoloration inflammation swelling discharge lesionsClitoris: _______cmMALE:

Pubic Hair: triangular distribution extending to abdomen scant absent others: ________________________

Penis: intact skin slightly wrinkled wrinkled smegma swelling inflammation nodules lesions tenderness immobility smooth/semifirm

Meatus: pinkish discoloration discharge:______________Scrotum: symmetrical asymmetrical marked asymmetry

discoloration tightening of skin darker in color enlarged nodules lesions non -tender tender

BOTH:Lymph Nodes: non-palpable swelling non-tender tenderFemoral Hernia: absent present

Inguinal Hernia: absent presentAnus: intact skin lesions tender non-tenderRectalWall: smooth non-tender tender nodular lesions

USE TO LOCATEABDOMINAL LESIONS (scars, rashes, etc.)

XV. AbdomenAppearance: uniform color striae lesions purple striae

tense, glistening skin (for ascites) dilated veinsConfiguration/Contour: flat globular protuberant

scaphoid symmetrical asymmetricalAbdominal Movement: symmetrical asymmetrical

peristalsis aortic pulsationsUmbilicus: sunken bulging herniaBowel Sounds:________/min normoactive hyperactive

hypoactive absentArterial Bruit: absent present ( aortic iliac

renal artery)Friction Rub: absent presentPercussion: Tympanitic at _____________________________

Dull at ___________________________________Fluid Wave: absent presentShifting Dullness: absent presentLiver: non-palpable enlarged smooth border nodular

hard tender non-tenderSpleen: non-palpable enlarged tender non -tenderBladder: non-palpable distendedOthers: muscle guarding direct tenderness rebound

tenderness masses: _____________________________CVA: tender non-tender

Grading Muscle Strength:

0 0% of normal strength; complete paralysis1 10% of normal strength; no movement, contraction of

muscle is palpable and visible

2 25% of normal strength; full muscle movement againstgravity, with support

3 50% of normal strength; normal movement againstgravity

4 75% of normal strength; normal full movement against

gravity and against minimal resistance

5 100% of normal strength; normal full movement againstgravity and against full resistance

XVII. Back and ExtremitiesSpine: straight curved kyphosis scoliosis lordosis Joints: non-tender tender redness warm swelling

crepitation nodulesROM: move smoothly full decresed at _______________Muscles: equal in size unequal in size atrophy

contractures tremors firm/tonic atonic

foot dropMovement: smooth coordinated flaccid spasticStength: equal unequal (GRADE: __________________)

Grading Murmur:

1 Very faint; heard during valsalva maneuver

2 Quiet

3 Moderately loud

4 Loud with palpable thrill

5 Very loud with thrill; with stethoscope

6 Very loud with thrill; without stethoscope

physical examination guide

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