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Physical Examination

The document describes the process for conducting a thorough physical examination of a patient. It involves inspecting, palpating, and auscultating/percussion different body systems and areas including general appearance, vital signs, skin, head, eyes, ears, nose, mouth, neck, chest, heart, breasts, abdomen, genitals, rectum, extremities, and reflexes. Key findings are noted for each area and abnormalities are documented. The exam allows for a comprehensive evaluation of the patient's overall health and physical condition.

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josna jesmon
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420 views5 pages

Physical Examination

The document describes the process for conducting a thorough physical examination of a patient. It involves inspecting, palpating, and auscultating/percussion different body systems and areas including general appearance, vital signs, skin, head, eyes, ears, nose, mouth, neck, chest, heart, breasts, abdomen, genitals, rectum, extremities, and reflexes. Key findings are noted for each area and abnormalities are documented. The exam allows for a comprehensive evaluation of the patient's overall health and physical condition.

Uploaded by

josna jesmon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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PHYSICAL EXAMINATION

General appearance and behavior

Body built: Thin/ Moderately built/obese

Posture: Erect /Kyphosis/Scoliosis/lordosis

Gait: Coordinated and steady.

Hygiene and grooming: Hygienic and well dressed /unhygienic

Appearance: Anxious/Pleisant/cheerful/depressed/worried.

Speech: Coherent/incoherent

Level of consciousness: conscious/unconscious.

Level of activity: active/dull

Level of nourishment: Nourished/unnourished

Height and Weight

Height in cm

Weight in kg

BMI= weight in kg/ height in m2

Inference:

Vital signs

 Temperature
 Pulse
 Respiration
 Blood pressure
HEAD TO FOOT ASSESSMENT
Skin

Inspection
Color - pallor/cyanosis/Erythema/Jaundice hyper or hypopigmentation
Lesions -primarylesions-macule/papule/Vesicle/nodule/wheal, pustule/cyst
Secondary lesion-erosion/ulcer/fissure/scaler/crust/scar/keloicl/lichennification

Palpation
Temperature - Warm/ cold and clammy
Moisture: Dryness/ smooth/ excessive moisture -
Texture - Soft/Rough/Thick
Turgor - Flexible/Elastic/Hard inelastic
Edema: Present/Absent/ pitting or Not, Grade.

Nails
Color -pink/cyanosis/pale
Cleanliness - clean/unclean.
Clubbing/Beau's line/koilonychias /splinter hemorrhage/paronychia
Capillary refill time :

Hair and Scalp


Color- Black/ grey
Distribution - Evenly/baldness/Thinning
Texture - Smooth/Rough hard//oily/brittle
Scalp - pediculosis/lesions/dandruff

Head
Size - Hydrocephalous/ Normocephalic/Microcephaly
Shape – Rounded/ oval
Symmetry/contour - Symmetrical/abnormal counter due to trauma , surgery
Face - pale/flushing/puffiness/edema
Facial feature: symmetric/ not

Eyes
Eyebrows
Symmetry -Aligned symmetrical/non symmetrical
Distribution -Eventually/loss of hair
Movement of brows: movable/Not movable
Eye lids
Color: Same as skin/not
Presence of ectropion/entropin/edema/ptosis/lesions
Eye lashes
Distribution -Eventually/not
Presence of follicle/stye/infection/dandruff
Lacrimal gland
Edema/ redness/excessive tear
Tenderness: present/ not
Conjunctiva
Normal/pallor/yellow/reddish/conjunctivitis/subconjuctival hemorrhage
Sclera
Color - white/changes
Cornea
Transparent, smooth, shiny or cloudy/ abrasions/irregular surface
Eye ball: protruded/sunken/Normal
Iris: Black/blue/brown/cloudy
Pupil -Dilated/pinpoint
PERRLA: Pupils equally rounded reactive to light and accommodation
Visual acuity - Normal/myopia/hyperopia/presbiopia.
Using aids - spectacles/lens
Extra Ocular movements: Possible/Not possible
Peripheral vision; Normal co-ordinated/Not

Ears
Inspection
Color - normal as face/not
Bleeding/lesions/masses/impacted cerumen/foreign bodies & discharges
Deformities: microtia /anotia /low set ears/other deformities
Palpation –Tenderness present / not

Nose and Sinuses


Nasal septum: deviated/ straight
Patency: obstructed-polyps/mass/lesions/foreign body/discharges
Epistaxis: present / not
Frontal &maxillary - painful/not painful.

Mouth and pharynx


Lips: pink/dark/swelling/redness//bleeding/cyanosis/lesions
Teeth: healthy/ poorly aligned missing teeth/loose teeth/dental carries/
stain/dentures.
Gums – Normal/Bleeding/ulceration/swelling//gingivitis
Mucosa - lesions/redness/leukoplakia.
Tongue: moist/dry, coated/not, glossits, fissured, cyanosis/pallor
Uvula- central & freely movable
Oropharynx/ Tonsils: redness/ normal/ enlarged
Neck
Inspection
Rom - Normal/limited
Jugular venous distention – present /not
Palpation
Trachea : central/ deviated
Lymph nodes –not palpable/Enlarged
Thyroid: Enlarged /normal
Carotid pulse: felt, -b/mt

Chest (posterior and anterior chest)


Inspection
Shape- normal/abnormal (Barrel/ pigeon/ funnel)
Symmetry -symmetrical/not
Respiratory Rate:
Dyspnea, use of accessary muscles/ICS - Bulging/retractions
Breathing pattern: Normal/abnormal(Cheyne stokes respiration/sigh/ Biot's/
kusummal’s respiration
Scar - present/absent.
Palpation
Lumps/masses/tenderness
Chest excursion: symmetric /not
Tactile fremitus: symmetric /not
Percussion
Resonance/dullness over the lung parenchyma
Auscultation
Breath sounds: Normal -Bronchial/Bronco-vesicular/Vesicular
If abnormal -Rhonchi/wheeze/crackles/friction rub/stridor

Heart
Inspection
Visible Pulsation: present/absent
Scar - present/absent/implanted devices
Palpation
Apical pulse/beat - present/absent, -- b/mt
Masses /nodes
Percussion: Dullness
Auscultation
Heart sound-s1 &s2 heard
S3 & s4 gallop/murmur/Friction rub.

Vascular: Varicosities/peripheral edema/phlebitis.


Breast and Axillae
Inspection: size/shape/symmerty
Pain/swelling/dimpling/skin lesion
Nipple: discharge/ dry scaling/fissure/ulceration/bleeding
Palpation: tenderness/lump/mass
Axillae: palpable lymph nodes/ not
Male - Gynaecomastia/lump

Abdomen
Inspection
Shape/skincolor/dilatedveins/visibleperistalsis/striae/lesions/rashes/hernia/mass/
ascites
Umbilicus:
Auscultation
Bowel sound: -- /mt
Palpation
Tenderness/mass/rebound tenderness
Abdominal girth:
Percussion - Tympani/dullness

Genitalia
Discharge/lesions/infections
Nocturia, dysuria, incontinence, dribbling, polyuria, infection, frequency,
urgency, hematuria
Female: problems with menstruation/vaginal discharge
Male: pain/sore/discharge/swelling

Rectum and Anus


Lesions/mass/cracks/fissure//hemorrhoids/nodules
Palpation (digital rectal examination) -Bleeding/clay or dark stool/BPH/mass.

Extremities
ROM/paim/swelling/edema/varicose vein/pulses/paralysis/deformities

Reflexes
Deep tendon: Biceps, triceps, brachioradialis, patellar, Achilles
Superficial: Corneal, Plantar, Gag, abdominal

Inference

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