Physical Examination

Anthropometric measurement:
Height :______ cm
Weight :______ kg
Body Mass Index :______
(BMI)

Vital signs :
Temperature :
Pulse :_____ beats/min
Respiration :_____ breaths/min
Blood pressure :_____ mm of Hg.

General appearance :
Body built : Strong built/ medium built/ poorly built
Posture : Erect/ bent
Gait : Steady/ unsteady
Grooming/Hygiene : Well groomed/Clean/ unclean
Appearance : Pale/Worried/Calm/Cheerful/Anxious

Mental status :
Consciousness : Conscious/ semiconscious/ stupor/ coma
Orientation to time, : Well oriented/ confused.
place and person
Attitude : Co-operative/negative/hostile/withdrawn
Affect / mood : Relevant/ irrelevant
Speech : Clear with adequate pace/ not clear/ irrelevant

Head to foot examination

Skin :
Colour : Normal/ paleness/cyanosis/ jaundice/ any other
Temperature : Warmth/ hyperthermia/ hypothermia
Texture : Regular and smooth/ dry
Turgor : Adequate/ inadequate
Lesions : Nil/macule/ patch/ papule/ plaque/nodule/tumor/wheal/
ulcer/fissure/crusts/scales
Oedema : Absent / Present
: Pitting/ non pitting oedema
: Grade_____
Hair
Colour : Black/grey/white/brownish/any other
Hair distribution : Equally distributed/ alopecia
Texture :Dry/Oily/Normal
Infection : Presence of dandruff/ Pediculi/fungal infection
Hair Strength : Silky and resilient/ thin and brittle hair
Nails
Colour : Pinkish/reddish/bluish
 Shape : Normal/ spoon shaped/ beau’s lines/clubbing/any other
Capillary refill : Normal- <2 sec/ Abnormal- >3 sec
Cyanosis : Present/ absent

Head
Shape of skull : Round, smooth skull contour- Normal/abnormal
Symmetry of skull : Normal/ increased in size/ decreased in size
Nodules/masses : Present/ absent
Face :
Symmetry of facial
features : Symmetrical/asymmetrical/ moon face/deformities
Scars : Present/ absent
Tics : Present/ absent
Facial puffiness : Present/ absent

Eyes :
Position : Above upper part of pinna/ below pinna/ protrusion
Eyebrows : symmetry/hair loss/movements- equal/unequal
Eyelids : Normal/symmetrical/asymmetrical/inflammation/lesions/
Oedema/ptosis/cysts/stye/entropion/ectropion
Eyelashes : Normal- outward curved/ inward curved/hair
loss/infection/dandruff
Lacrimal glands : Normal/ excessively dry/excessively moist/ Patency
Conjunctiva
Palpebral : Pink/lesions/inflammation/swelling/pale
Bulbar : white and normal/icterus/red/congested
Sclera : White/Yellow/Red/foreign bodies
Palpebral fissure : equal/ unequal
Pupils
Size : 2mm/3mm/4mm/5mm/6mm/any other/ Equal
Reaction to
Light : Reactive/ non- reactive/ Sluggishly reactive
Accommodation : Converge and constrict/ diverge and dilate
Cornea : Clear and transparent
Anterior chamber : Normal/shallow
Corneal reflex : Blinking present/ absent
Field of vision : Normal/abnormal
Visual acuity : Normal/ use of spectacles/ Cataract
Colour discrimination : Normal/ Abnormal
Eye movements : Equal/ unequal
Deformities : Strabismus

Ears :
Symmetry in position : Symmetrical/asymmetrical
Shape : Bean shaped/ abnormal shape/parallel
Auricle : Pain/ nodules/ recoils when folded
External ear canal : Normal/ abnormal/clean/unclean/presence of cerumen/
Discharge/ redness/ swelling
Mastoid process : Normal/tenderness
Hearing acuity : Normal/ use of hearing aids
Nose :
Structure : Symmetrical/Asymmetrical
Nares : Patent/not
Nasal flaring : Present/absent
Nasal septum : Normal/deviated/perforation
Nasal cavity : Normal/swelling/lesions/drainage/polyps/crusted secretions
Sinuses : Normal/tenderness/swelling/ thickening
Olfaction : Intact or normal / distorted- abnormal/ anosmia

Mouth :
Structure : Symmetrical/ asymmetrical
Lips
Symmetry : Symmetrical/asymmetrical/oedematous
Shape : cleft lip/normal
Colour : cyanosis/ Pink/dry
Lesions : cracked / fissures/cheilosis/stomatitis/ /
Gums : Pink- normal/bleeding/lesions/inflammation/retracted/
Hypertrophy
Teeth : Colour/no. of teeth/dentures/dental caries/plaque/ dental
fillings/malocclusions
Temporomandibular joint: no crepitus/ tenderness
Oral cavity : Pink and moist/ulcers/ white patches/nodules/ halitosis
Palate (Hard/ soft) : Normal/ cleft palate
Tongue : Symmetrical/asymmetrical/pink/cyanosis/pallor/moist /dry
Fissures, clean/coated/tongue tie
Tonsils : Normal/ enlarged
Gag reflex : present/absent
Neck :
Range of motion : Possible/ Limited/not possible
Lymph nodes : Enlarged/ not enlarged
Thyroid : Normal/ enlarged
Trachea : Midline – normal/ deviation
Carotid artery : Normal/ abnormal
External jugular veins : No distension- normal/ distended

Chest :
Shape : Symmetry/ pigeon shaped/ barrel shaped/surgical scars
Respiratory movements: normal/ / unilateral movement of chest/ Retractions
Respiratory rate : normal/ increased/ decreased
Breathing pattern : normal/ orthopnoeic/ dyspneic/ hyperventilation/ Cheyne-
Stoke’s respiration/any other.
Cough :present/ absent/ productive cough
Fremitus : normal/abnormal
Breath sounds :normal/ bronchovesicular/ crackles, wheeze, rhonchi,
Friction rubs
Pulsation : Apical pulse felt/heaves/thrills/ murmers/ carotid bruits

Breast and axillae :

Symmetry : symmetrical/not/ engorgenment
 Nipple : Normal/ inverted / retracted / flat
Lesions : orange peel skin/ absent/dimpling/ fixed/ Pain/ tenderness/
swelling/lumps/cysts/ palpable nodes
Discharges : Present/ absent
Axilla : Normal/ abnormal- lumps/redness

Abdomen :
Contour : Flat/ rounded/ scaphoid
Symmetrical/ asymmetrical
Umbilicus : Protruded/Infection/ discharge/ hernia present / absent
Distension : Present/ absent
Surgical scars : Present/ absent
Lesions : Striae/Pigmentation
Abnormal masses : Present/ absent
Bowel sounds : Present- normal/ hyperactive/ hypoactive
Bruit sound : Present / absent – normal
Tenderness : Present/absent
Abdominal girth :
Liver :Palpable/nonpalpable
Abdominal reflex : Present/ Absent
Visible pulsations : Present/ Absent
Visible peristalsis : Present/ Absent
Muscle guarding : Present/ Absent

Back :
Normal (straight)/Kyphosis/ Lordosis/ Scoliosis
Presence of bed sore/ decubitus ulcer
Tenderness/ Oedema/ redness/ abnormal protrusion

Genitalia :
Males :
Urethral opening: Hypospadiasis/ Epispadiasis
Scrotum : swelling/pain
Voiding : normal/ retention/ incontinence/ catheterised/ oliguria/
polyuria/dribbling of urine.
Others : Presence of enlarged lymph nodes/ inguinal hernia
Females:
Presence of any rashes, redness
Presence of abnormal bleeding/discharge per vagina
Presence of oedema in the genital region
Presence of enlarged lymph nodes/ tenderness
Voiding : normal/ retention/ incontinence/ catheterised/ oliguria/
polyuria/dribbling of urine.

Anal region :
Presence of any haemorrhoids/ anal fissures/ lesions/masses/bleeding/ tone of
anal spincter

Extremities :
Upper extremities :
 Symmetrical position, shape of bones and muscles
Deformities :Present /absent
Range of motion : Possible/ limited/not possible
Presence of tremors/ contractures/ muscle weakness
Any swelling/ tenderness
Muscle tone :normal/flaccid/spastic
Peripheral pulses
Digits : polydactyly/ syndactyly
Presence of IV cannula

Lower extremities :
Symmetrical position, shape of bones and muscles
Presence of tremors/ contractures/ muscle weakness/Deformities/ foot drop
Range of motion : Possible/ limited/ not possible
Enlargement/ swelling of joints/ lymph nodes
Muscle tone :normal/flaccid/spastic
Peripheral pulses
Presence of IV cannula
Varicose veins
Presence of pedal edema: Pitting/non pitting

Systemwise examination

Nervous system:
Mental status :
GCS score :
Pupils : PERRLA
Balance :
Gait :
Cranial nerves assessment:
Assessment of tactile and sensory functions: one and two point discrimination/
stereognosis/extinction/ graphesthesia
Light touch and pain sensations:
Reflexes :
Superficial: corneal/ abdominal/ gag reflex
Deep tendon: biceps/ triceps/
patellar/calcaneal/
Babinski
Coordination : finger to nose test/ rapid alternating
movements/ heel knee shin test
Respiratory system:
Inspection:
Respiratory rate/ rhythm/ depth
Chest expansion:
Chest shape : normal/ barrel/ pigeon/ funnel/ flail
Anteroposterior diameter to lateral diameter:
Use of accessory muscles:
Nasal flaring/ mouth breathing
Breathing pattern : Kussmaul’s breathing/ Cheyne-Stoke’s breathing/ Biot’s breathing
 Respiratory support: on oxygen through mask or prongs/ BIPAP/ CPAP/ Ventilator /
ETT/ Tracheostomy

Palpation:
Mass/ tenderness/ palpable crepitus/ tracheal deviation
Tactile fremitus : symmetrical/ asymmetrical
Percussion:
Resonance/ hyperresonance/ tympany/ dull/ flat
Auscultation:
Breath sounds (bronchial, bronchovescicular, vesicular)
Adventitious breath sounds: crackles, wheezes, pleural friction rub, rhonchi, stridor
Air entry : equal/ symmetry
Cardiovascular system:
Inspection:
Cyanosis/ jugular vein distension/ precordial heaves/ visible carotid pulsations/
clubbing of nails/ surgical scars
Palpation:
Apical pulse
Capillary refill
Percussion
Dullness
Auscultation
Pulse: rate, rhythm
Pulse deficit
Arterial bruit
Heart sounds: S1,S2 normal
S3,S4/ murmers/ bruits/ pericardial friction rub
Gastrointestinal system:
Inspection:
Shape/Colour/texture/scars/striae/rashes/ lesions/visible peristalsis/ dilated veins/
visible pulsations
Abdominal girth:
Umbilicus: inverted/ central/ protruded/ discharge
Stoma
Intake: oral/ NPO/ RT feeds/ Gastrostomy/ Jejunostomy/TPN
Auscultation:
Bowel sounds: rate: hypoactive/hyperactive; pitch, tingling, gurgling, rushing
Bruits: Present/ absent
Percussion:
Tympany heard throughout with liver and splenic dullness
Palpation:
Abdomen: soft, nontender, no mass or rebound tenderness
Muscle tone: firm/ relaxed
Liver and spleen: enlarged or not
Genitourinary system:
Inspection:
Edema/ urine output/ incontinence/ urgency/ frequency of
urination/discoloration/ulcers
Palpation:
Bladder distension/lymph node/mass/tenderness
Percussion:
Tenderness/ symphysis pubis- dullness
Musculoskeletal system:
Inspection:
Gait/ range of motion/ deformity
Posture
Swollen joints
Palpation:
Grade of muscle strength
Sternocleidomastoid : Grade ___
Trapezius : Grade ___
Deltoid : Grade ___
Biceps : Grade ___
Triceps : Grade ___
Wrist & Finger muscles: Grade ___
Grip strength : Grade ___
Hip muscles : Grade ___
Hip abduction : Grade ___
Hip adduction : Grade ___
Hamstrings : Grade ___
Quadriceps : Grade ___
Muscles of ankle and
Feet : Grade ___

Joints: crepitus/ temperature/ tenderness/ nodule

Muscle groups: firm/ symmetrical/ tender/mass
Peripheral vascular system:
Inspection:
Cyanosis/varicosities
Palpation:
Peripheral pulse: rate, rhythm,
Capillary refill
Limbs: temperature, moisture, edema, colour
Endocrine system:
Inspection:
Enlarged thyroid/ muscle wasting/ generalised edema
Palpation: thyroid enlargement