CONDUCT OF PHYSICAL EXAMINATION

I. General Survey
Observe for: - race, sex
- General physical; development
- Nutrition state
- Mental state (oriented, disoriented, confused, responsive,
unresponsive, incoherent, somnolent, unconscious)
- Evidence of pain, restlessness
- Body position, stature, gait
- Clothes, age, hygiene, grooming
- Emotional status, including attitudes or mood
- Apparent state of health, in acute distress or chronically ill
II. Vital Signs and Clinical Measurement

Include actual body weight, height, temperature, blood pressure (BP), pulse rate (PR),
respiratory and heart rate (HR)

III. Skin
Observe for:
1. Color – cyanosis, pallor, jaundice, flushing, pigmentation
2. Lesions – macule, papule, etc. (distribution type, configuration, size)
3. Vascularity – evidence of bruising, bleeding, edema, vascular and purpuric lesion
(angioma, purpuras, petechiae)
4. Moisture – dryness, sweating, oiliness
5. Texture - rough, smooth, scaly
6. Temperature – warm, hot, cold
7. Mobility and turgor – firm, loose, wrinkles, edematous, turgid, skin rapidly resumes
its original shape: loss of turgor is indicated by persistence of the skin fold for a time
pinching.
8. Hair and nails – brittleness, presence or absence, quality, quantity and distribution

IV. Head – normally the skull and face is symmetrical, with distribution of hair varying from
person to person.
1. Hair – quantity and distribution
Texture – dry, brittle, luster, color
2. Scalp – lice, dandruff, lesions, laceration, tenderness or swelling
3. Skull – size, contour, configuration, depression
4. Face – portrays emotions, pain intelligence and understanding
a. Observe for expression – flat. Expressionless, wide eyed, confused or
quizzical expression, angry, excited
b. Symmetry
c. Edema
 d. Masses
e. Involuntary movements – tics, spasmodic contraction
f. Shape – round, oval, triangular
g. Skin – color and pigmentation
5. Forehead – smooth, furrowed with wrinkles
6. Eyes – general expression, use of supportive aid such as contact lens, eyeglasses.
a. Eyebrows – quality of hair, presence of flakes, scars, lesion, etc.
b. Eyelids – lid margins are normally clear, the lacrimal duct opening (puncta) is
evident at the nasal side of the upper and lower lids.

Observe for:

- Height of palpebral fissures (longitudinal openings between the

eyelids which appear equal in size when the eyes are open)
- Blinking reflex
- Pessence of edema, hemmorrhage, hematoma
- Color – redness, cyanosis
- Direction of lashes (outward, inward)
- Lid eversion or inversion
c. Bulbar and palpebral conjunctive – color (pale, pink, red), growth or lesions
d. Sclerae – clear color pigments
e. Cornea and lens – check transparerncy, opacities, ulcerations, scratches
f. Irish – color
g. Pupil – normally constrict with light and when looking at near objects and dilate in
the dark and when looking at near objects. They are round and can change size from
very small (pinpoint) to large (occupying the entire space of the iris)
h. Eyeballs
- Position and allignm,ent
- Prominence of eyeballs – sunken, bulging
- Eye movement
1. Extra ocular movement – movement of the eyes in conjugated
fashion
2. Nystagmus – rapid, lateral horizontal or rotary movement of the
eye: may be normal as a result of fatigue
3. Strabismus – deviation of one eye so that the visual axis is no
longer parallel to that of the other eye
4. Convergence - ability of eye to turn in and focus on a very close
object
7. Ears – symmetry
a. Pinna – observe of size, shape, color, lesions, masses, swelling – discharge –
whether serous, purulent, sanguinous; observe odor - tenderness; consistency of
the cartilage.
 b. External canal – normally clear with perhaps minimal cerumen – examine for
discharge; impacted cerumen; inflammation; masses, foreign bodies, etc.
c. Tympanic membrane – examine for color, luster, shape, position, transparency,
integrity, and scarring.
d. Auditory acuity – distance within which one can hear spoken words or a watch tick (
occlude one ear at a time when testing). A person with normal hearing can hear
whispered word from approximately 4.5 meters (15 feet and a watch tick from 30
cm ( 1foot)
e. Response to mechanical test.
- Weber test – test for lateralization of vibration
- Rinne’s test – compares air and bone conduction
8. Nose – inspection the external surface of the nose for symmetry color, shape and size
9. Mouth
a. Lips – color, moisture; masses; ulceration; fissure; lessions; edema; congenital
defect
b. Teeth – number (31 adult); arrangement; general condition; carries; discoloration;
fillings; absence of one tooth or more; abnormal dental shape and use of artificial
teeth.
c. Gum – color; texture; swelling; retraction; bleeding; lessions
d. Buccal mucosa – normally the mucosa should be pink, smooth and fine lessions
e. Tongue – is normally midline and covered with papillae, which vary in size from the
tip to the back. Observe for the size; color; thickness; lesions; moisture; symmetry;
deviation from midline.
f. Hard palate and soft palate; uvula – observe for ulcerations congenital defects and
symmetry when the patient says “ah”
g. Tonsils – size, ulceration, exudate; inflammation
h. Odor or breathe – ability to masticate AND SWALLOW. Odor – use of tabacco or
alcohol, poor dental hygiene; gingivitis, acetone breath – for diabetic coma, musty
odor for severe liver disease; urinary odor – for uremic status.
V. NECK
a. Inspect all the areas of the neck anteriorly and posteriorly for muscular symmetry,
masses, unusual swelling or pulsations and range of motion – which includes right and
left lateral, right and left rotation, reflexion, extension, and hyperextension. The neck
should move easily without any discomfort.
b. Thyroid – inspect enlargement; which may not be visible, especially in extremely thin
persons. If palpable, it is not normal smooth, without nodules, masses or irregularities
or bruits (gushing sound) produced by blood moving through a narrow vessel.
c. Trachea – palpate for deviation
d. Lymph nodes and salivary glands – cervical nodes – not normally palpable unless the
patient is very thin.
e. Carotid arteries lying at 30 to 40 degrees angle; neck should not be flexed.
f. Observe for any limitation of movements (e.g. torticollis)
VI. BREAST
a. Nipples and areolae – position, pigmentation, inversion, discharge, crusting and masses.
b. Breast tissue – size, shape, color, symmetry, surface, contour, skin, characteristics, level
of breast; note for any retraction or dimpling.
c. Axilla – rashes, infection, lymph nodes

VII. CHEST AND LUNGS

A. Inspection
Observe for
- Symmetry of the posterior chest
And the posture and mobility of the
Thorax upon respiration, retraction of
intercostals spaces.
Normal findings
-Thorax is symmetrical, it moves easily
and without impairment upon registra-
tion. There are no bulges nor retraction
Of the intercostal spaces.

-Note the anteroposterior diameter in - The AP diameter of the thorax in

Relation to the internal diameter in relation the lateral diameter is
Relatiion to the lateral diameter of approximately 1:2
The chest.

-Examine for skin lesion, masses, cyanosis.

-Respiratory rate and rhythm – regular, irregular, noisy, deep, fast, slow.
-Presence of:

Dyspnea – exertion, paroxysmal, nocturnal, orthopnea

Cough – single or paroxysmal
- Unproductive cough – short, sharp, no production of sputum
- Productive cough – sputum is raised with rattle and distinctive
sound – brassy when it is unproductive and has strident quality
- Whooping – charactirized by long strident, inspiratory, noise
(whoop preceding the cough)
- Hemoptysis – spitting or coughing up of blood
- Describe sputum – color amount, odor, time of day
- Hiccup or hiccough – sudden involuntary diaphragmatic contraction
producing an inspiration interrupted by glottial closure with a
characteristic sound
- Rib cage – shape e.g.funnel, barrel
- presence of tubes and drainage
- spinal deformeties:
- Scoliosis – abnormal anterior curvature of the spine
- Lordosis – the normal anterior lumbar curvature is exaggerated
- Kyphosis – exaggerated of the normal thoracic convexity
 B. Palpation
1. Palpate the ribs and costal margins for symmetry, mobility and tenderness and the
spine for tenderness and vertebral position.
2. Atreas of tenderness, masses, inflammation.
3. Fremitus – sensation felt by the hand when place on the part.
- Ask patient to say “99” posteriorly, it is generally equal throughout
the lung fields. It may be decreased or absent anteriorly, when
posture is not correct, or when excessive tissue or underlying
structures are present.
4. Crepitation – fine cracking feeling due to air in the soft tissue, as in subcutaneous
emphysema.
5. Pleural friction rub – it is leathery or grating feeling resulting from rubbing one
pleural surface against another and is due to the presence of inflammation or
absence of adequate LUBRICATING FLUID.
C. Percussion
- Detect changes from normal density of the organ
- Resonance: dull, flat tympanitic
D. Auscultation – must be done systematically and symmetrically in a top to bottom
direction.
- Quality of breath sound; clear, coarse, diminished, absent
- Rales – sound in the lung from the movement of fluid or exodates in
the airway or passage of air through constricted tube
a. Coarse rales or rhochi or gurgling of fluid or exudates in the
airway or passage of air through constricted tube
b. Moist, medium, crepitant rales – arises from relatively thin fluid
moving in bronchi or bronchioles
VIII. Heart
A. Inspection
- Inspect for bulging, heavy or thrusting in the pericardium
- -Note of pulsation
- Pericardial bulge – protrusion of bony thorax once right ventricle
hypertrophies due to enlarge from CHF
B. Palpation
- Location of apical beat – note also rate, rhythm, duration
- -pressence of:
-Thrills – palpable murmur – fine buzzing sensation similar to
that felt while a purring cat
-Note size and force of PMI (point of maximal impulse)
C. Percussion
- Define cardiac borders or areas of cardiac dullness
D. Auscultation
 - Count cardiac rate, note cardiac rhythm – regular, irregular, rapid,
slow (tachycardia; bradycardia)
- Abnormal; beats – bigemal, trigeminal, premature, missed
- Palpitations – pounding, fluttering, missing, stopping
- Murmurs – turbulent blood flow, note pitch, quality, grade loudness
radiation
IX. Abdomen
A. Inspection
- Be sure patient has an empty bladder, lying comfortably and
abdomen full exposed
1. Observe the general contour of the abdomen – flat,
protuberant, scaphoid, concave, local bulges, symmetry, visible
peristalsis aortic pulsations.
2. Umbilicus – contour, hernia
3. 3. Skin – scars, rashes, pigmentation, etc.
B. Auscultation – abdomen Hve the familiar “growing” sound, it has 5-35 bowel sound per
minute. There shpuld be no rubs or bruits.
1. Bowel sound – pitch, duration, absence, increase, gurgling.
2. Bruit – aorta and renal arteries-abnormal – abnormal blood flow
C. Percussion
- Note tympani and dullness (tympani normally predominates)
- Masses; fluid level
D. Palpation (Light)
- Determine muscle tension and resistance, tenderness and
superficial masses or organ enlargement
- Skin fold test for dehydration
E. Palpation (deep)
- Masses – size, shape, consistency, mobility, location
- Abnormal distension – 6 fs – fluids, fat, flatus, fetus, feces, fetal
growths.
- Area of tenderness, deep and rebound tenderness
- Palpable organs: liver, kidney, cecum and abdominal aorta
- Lymph nodes – inguinal and femoral areas
- Note: palpation is nopt done in the abdomen if contraindicated (e.g.
aortic aneurysm)
X. Genito – Urinary
- Observe distribution of pubic hair, size, shape, color lesion, edema,
nodules
- Penis size, location and placement of urethral meatus, diacharge,
lessions
- Scrotum – size, contour, skin color, lessions, symmetry, shpe,
tenderness
 - Inspect mons pubis, labia majora, perineum, distribution of pubic
hair, inflammation, swelling, lessions, growths.
- Separate labia and inspect vestibule – note inflammation, swelling,
lessions, discharges, atrophy, abnormal odor, clitoris, urethral
opening, vaginal introitus
- Groin – note any scars, lesion, enlarge lymph nodes, hernia, bulging
- Rectum – pereneal region – any discoloration, inflammation, skin
lessions, scars, tissues, fistula, haemorrhoids
XI. Extremities

Upper Limb

o Shoulder and arms – inspect for swelling, deformity, athrophy, symmetry,

palpate sternoclavicular joint at sternum, grooves and head of humerus for
tenderness, nodules, fluid (note: range of motion).
o Elbows – note for swelling, nodules, deformities, observe range of motion.
o Forearms – flex, extend, supinate, pronate (note range of motion), pain.

Lower Limb

o Hip joint and thigh – range of motion, any pain tenderness; is one leg longer
than the other, any deformities, scars, amputation.
o Leg and knees – range of motion, deformities, edema, inflammation
o Foot – deformities (clubfoot, flastfoot) alignment, tenderness, range of motion
of ankle joint.
o Nails – color, deformities, lesions
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4 AREAS OF ABDOMEN/4 QUADRANT OF ABDOMEN
THE NINE REGIONS OF THE ABDOMEN