USE TO LOCATE

PHYSICAL EXAMINATION GUIDE PAIN (red), LESIONS (blue), EDEMA (green)

I. General Information
Name of Client: __________________________________________________________ Age: ________ Sex: ________
Unit/Ward: ______________ Bed No.: _________ Examiner: _______________________________________________
Home Address: ____________________________________________________________________________________

II. Vital Signs and Anthropometric Measurements GLASGOW COMA SCALE

T: ___________________ □ oral □ axillary □ rectal □ tympanic EYE OPENING
BP: __________________ □ sitting □ lying □ standing Spontaneous 4 --
PR: _______________/min RHYTHM: □ regular □ irregular To verbal command 3 --
VOLUME: □ absent □ thready/weak □ bounding □ normal To pain 2 pinch pinky nail, deep sterna
HR: _______________/min □ regular □ irregular rub, sub-orbital squeeze,
RR: _______________/min DEPTH: □ normal □ deep □ shallow trapezius squeeze
RHYTHM: □ regular □ irregular No response 1 --
QUALITY: □ effortless □ labored □ use of acce.muscles VERBAL RESPONSE
WEIGHT: __________kg HEIGHT: __________cm
Oriented & converses 5 If patient is intubated, in a
BMI: ______________kg/m2 MUAC: ___________ cm
Disoriented & converses 4 mechanical ventilator,
WAIST CIRC: _______cm HIP CIRC: _________cm
Inappropriate words 3 indicate Vx
WAIST-HIP RATIO: _____________
HEAD C.: ______ cm (<24 mo unless with genetic/CNS disease) Incomprehensible sound 2
No response 1 USE TO GAUGE PAIN
ABDOMINAL GIRTH: ____________________ (as appropriate)
MOTOR RESPONSE
BMI INTERPRETATION EDEMA GRADING Obeys verbal commands 6 --
<17 = ext. underwt. 1+ = 2mm deep Localizes pain 5 ask px to close eyes & pinch
17 – 18.5 = underweight 2+ = 4mm deep hand, ask where pain source
18.5 – 24.9 = normal 3+ = 6mm deep is
25 – 29.9 = overweight Withdrawal to pain 4 remove hand/body part from Primary Skin Lesions:
>30 = obese>40 ext. obese)
4+ = 8mm deep
pain source □ Macule: flat, 1mm to 1cm
□ Patch: flat, >1 cm
III. General Survey Abnormal flexion in 3 --
□ Papule: circumscribed, elevated, <1cm
Hygiene: □ clean/neat □ unkempt □ halitosis (○ ammonia- response to pain □ Plaque: elevated, >1cm
odor ○ acetone-odor ○ foul-odor) □ bromhidrosis (DECORTICATE) □ Nodule: elevated, deeper than papule, 0.5 – 2cm
Nutrition: □ well-nourished □ obese □ cachexic Extension in response to 2 -- □ Tumor: elevated, deeper, may be irregular in shape, >2cm
General Appearance: □ relaxed □ signs of distress (○ pain, pain (DECEREBRATE) □ Vesicle: circumscribed, with serous fluid, <0.5cm
○ cardio-respiratory ○ anxiety) No response 1 -- □ Bulla: circumscribed, with serous fluid, >0.5cm
Emotional State: □ calm □ worried □ restless □ tense GCS:_____ E:___ V:___ M:___ □ Pustule: vesicle o bulla filled with pus
Development: □ well □ fairly □ poorly □ looks accdg to age □ Cyst: >1cm, fluid-filled, deeper than vesicle and bulla
Looks □ younger □ older □ Wheal: reddened, irregular in shape
Level of Consciousness: □ conscious □ lethargic IV. Integument
Secondary Skin Lesions:
□ obtunded □ stuporous □ comatose General Color: □ normal □ pallor □ cyanosis □ jaundice
□ Atrophy: dry, paperlike, wrinkled skin surface
Coherence: □ coherent □ incoherent □ erythema □ vitiligo
□ Erosion: moist, shallow depression, epidermis only
Orientation: □ oriented to □ disoriented(○time ○person ○place) Texture: □ smooth □ rough □ others: _____________________ □ Lichenification: rough, thickened, hardened area
Temperature: □ warm □ cool □ others: ___________________ □ Scales: shedding flakes of greasy, keratinized tissue
V. Nails Turgor: □ good □ fair □ poor □ Crust: dry blood, serum, or pus left on the surface
Color: □ pink □ pallor □ cyanosis Moisture: □ normal □ dry □ wet/clammy □ oily □ Ulcer: deep, irregularly-shaped, up to dermis or subQ
Nail Plate: □ convex □ spoon-shaped/koilonychia □ clubbing Lesions/Rashes: (see illustration) □ Fissure: linear crack with sharp edges
Capillary Refill: ______ seconds □ normal □ delayed Edema: □ pitting □ non-pitting (GRADING: ____________) □ Scar: flat, irregular connective tissue after wound healing
Texture: □ smooth □ thick □ thin □ beau’s lines Pressure Ulcer: GRADING:_______________ □ Keloid: elev., irreg., darkened area of excess scar tissue
Inflammation: □ negative □ positive (charac.:______________) □ Excoriation: linear erosion
VI. Head VIII. Eyes IX. Ears
Configuration: □ normocephalic □ smooth contour Lids: □ symmetrical □ asymmetrical □ edema/swelling (○R ○L) Auricles: □ symmetrical □ asymmetrical □ aligned with
□ others: ______________________________________ □ ptosis (○R ○L) outer canthus of the eye □ low-set ears
□ nodules □ masses □ depressions Periorbital Region: □ edema □ sunken □ discoloration Color: □ same as facial skin □ pallor □ cyanosis
Fontanelles: □ closed □ open □ sunken □ bulging Eyelashes: □ equally distributed □ curled outward Texture/Elasticity/Tenderness: □ mobile □ firm □ non-
Facial Features: □ symmetric □ slightly symmetric □ turned inward tender □ tender □ pinna recoils after folded
□ asymmetric □ exophthalmos □ moon-faced Eyebrows: □ evenly distributed □ loss of hair □ symmetrical Gross Abnormalities: __________________________
□ myxedema □ asymmetrical □ skin intact □ scaling □ flaking □ equal External Canal/Middle Ear: □ impacted cerumen □
Facial movements: □ symmetric □ asymmetric □ involuntary movement □ unequal movement discharge (○foul smelling ○serous ○purulent ○mucoid)
facial movements Conjunctiva: □ pinkish □ pale □ red □ extremely pale □ Gross Hearing: □ symmetrical □ deafness (○R ○L)
Hair: □Fine □Coarse □Dry □ Normal dist.□ Alopecia□ Bald spot extremely red □ lesion □ discharge □ with hearing devices: ___________________
Scalp: □ Clean □ Dandruff □ Lice □ Lesions Sclera: □ anicteric □ subicteric □ icteric □ hemorrhages CN 8 (Acoustic)
Lacrimal sac and NL duct: □ non-tender □ tender Gross Hearing/ □ Symmetrical □ Deafness
CN 7 (Facial) Cornea: □ transparent □ shiny □ smooth □ arcus senilis Whisper test R/ L
Raise both eyebrows □ able □ one side (R/L) □ unable Corneal light reflex test: □ (+) sensitivity □ (-) sensitivity Weber’s test □ Negative □ Positive
Frown □ able □ unable Iris: □ transparent □ dicoloration □ opacity □ cloudiness (Lateralization)
Close both eyes tightly □ able □ one side (R/L) □ unable Pupils: R:_____mm L:_____mm □ equal □ unequal Rinne Test (Air and □ Positive □ Negative
Show upper teeth □ able □ unable Reaction to Light: R □ brisk □ sluggish □ fixed Bone conduction) AC>BC BC > / = AC
Show lower teeth □ able □ unable L □ brisk □ sluggish □ fixed
Smile □ able □ unable Reaction to Accomodation: □ equal □ unequal X. Nose
Puff both cheeks out □ able □ one side (R/L) □ unable Peripheral Vision: □ intact □ smaller than normal □ half-vision Nasolabial Fold: □ symmetrical □ shallow (○R ○L)
Extraocular Muscle Test: □ intact □ non-intact □ nystagmus Septum: □ midline □ deviated (○R ○L) □ perforated
Motor Function (Part I - upper) Visual Acuity: □ grossly normal R:____/____ L:____/____ Mucosa: □ pinkish □ pallor □ cyanosis □ redness
Gait: □ Coordinated □ Uncoordinated □ Staggering □ wears eyeglasses/contact lenses (grade: R:___ L:___) □ discharge (○bloody ○serous ○purulent ○mucoid)
□ Shuffling □ Stumbling □ Unable to walk alone Patency: □ both patent □ obtructed (○R ○L)
□ walks with assistive devices □ Masses/Lesions
Romberg Test: □ Negative □ Positive Sinuses: □ tender □ non-tender
Standing on one foot with eyes closed: □ >5 secs □ < 5 secs Gross Smelling: □ symmetrical □ olfactory def.(○R ○L)
Heel-Toe-Walking: □ able □ unable CN1 (Olfactory)
Toe Walking: □ able □ unable Object
Heel Walking: □ able □ unable
Finger-to-Nose: □ able □ unable □ Identified
Finger to Nose and to Nurse’s finger: □ able with rapidity □ Identified
□ misses and moves slowly
Fingers to fingers: □ able □ unable XI. Mouth
Fingers to thumb: □ able □ unable Lips: □pinkish □ pallor □ cyanosis □ dry/crack □ lesions
Supination & Pronation of hands: □ able □ unable Mucosa: □pinkish □pallor □cyanosis □moist □dry
Tongue: □ midline □ deviated to (○R ○L) □ atrophy
VII. Neck □ fasciculation □ lesions
Trachea: □ midline □ deviated to (○ right ○ left) Teeth: □ complete □ incomplete □ braces □ retainers
CN 3 (Oculomotor) and CN 4 (Trochlear)
Lymph Nodes: □ nonpalpable □ palpable □ enlarged □ tender Caries (red), Missing (green), Dentures (blue)
Reaction to light (direct): R □ Brisk □ Sluggish □ Fixed
Thyroid: □ nonpalpable □ enlarged Gums: □ pinkish □ pale □ bleeding □ tender □ non-
L □ Brisk □ Sluggish □ Fixed
Range of Motion: □ normal □ rigid tender
Consensual Response: □ Present □ Absent R/L
Carotid Pulse: ____________/min □ symmetric □ asymmetric Speech: □ intact □ slurred □ aphasic □ others:
Reaction to accommodation: □ Uniform □ Unequal
RHYTHM: □ regular □ irregular _____________________________________________
Convergence: □ Uniform □ Unequal
VOLUME: □ absent □ thready/weak □ bounding □ normal Cough Reflex: □ present □ absent
CN 3, 4, 6 (Oculomotor, Trochlear, Abducens)
NVE: ____________ ˚ Six Ocular Movements: □ Coordinated □ Nystagmus
Masses: □ present □ absent CN 5 (Trigeminal – Opthalmic branch)
Tonic Neck Reflex: □ present □ absent Corneal Sensitivity: □ Responsive □ No response R/L
CARIES (red), MISSING TEETH (green), DENTURES (blue)
CN11 (Hypoglossal)
Base of Tongue: □ Smooth □ Swelling □ Ulceration
Tongue Movement: □Symmetrical □Asymmetrical
Tongue Strength: □ Strong □ Weak
CN 5 (Trigeminal – Mandibular branch)
Clench teeth: □ able □ unable
CN 9 and 10 (Glossopharyngeal and Facial)
Voice Quality: □ Normal □ Hoarseness □ Nasal Quality
Difficulty in Swallowing: □ Absent □ Present
Gag Reflex: □ Absent □ Present
XII. Pharynx
Uvula: □ Midline □ Deviation to R L
Mucosa: □ Pinkish □ Pale □ Reddish
Tonsils: □ Not inflamed □ Inflamed □ Exudates Grade: ____
I II III IV
Normal Tonsils bet. Tonsils touch Extend to
Pillars & uvula the uvula midline
XIII. Chest and Lungs Murmurs: □ absent □ present (GRADE: _________)
Inspiration:Expiration ratio: ____ : ____ Best heard at _____________________________
Breathing Pattern: □ Effortless □ Hyperpnea □ Tachypnea Grading Murmur:
□ Dyspnea □ Use of accessory muscles □ Grunting 1 Very faint; heard during valsalva maneuver
Shape: APL ratio: ____ : ____ □ barrel □ funnel □ pigeon 2 Quiet
Chest Expansion: □ symmetrical □ decreased/lag (○R ○L) 3 Moderately loud
Tactile Fremitus: □ symmetrical □ decreased or □ increased 4 Loud with palpable thrill
@ (○R ○L) lung field 5 Very loud with thrill; with stethoscope
Percussion: □ resonant □ dull □ tympanitic □ hyperresonant 6 Very loud with thrill; without stethoscope
Breath Sounds: □ vesicular over ____________
□ bronchovesicular over ____________ XV. Breast and Axillae
□ bronchial over _____________ Size: □ symmetrical □ asymmetrical
Adventitious Breath Sound: □ absent □ fine crackles Appearance: □ same as color of abdomen or back
□ coarse crackles □ wheezes □ rhonchi □ stridor □ discoloration □ striae □ dimpling/retraction
□ hypervascularization □ swelling □ edema
Sound Character Indication Areola: □ round □ oval □ symmetrical □ asymmetrical
Vesicular Insp. > Exp. Normal Nipples: □ round □ everted □ inverted □ symmetrical
Bronchovesicular Insp. = Exp. Normal size □ asymmetreical size □ discharge: ___________
Bronchial Exp. > Insp. Normal Lymph Nodes: □ palpable □ non-palpable
Fine Crackles* Soft, high-pitched (5- Pneumonia, Breast tissue: □non-tender □tender □mass □ nodules
10msec) fibrosis, early □ discharge: ____________________________
Coarse Crackles* Louder, lower in pitch CHF, bronchitis,
(20-30msec) bronchiectasis XVI. Abdomen
Wheezes High-pitched; have Narrowed airways Appearance: □ uniform color □ striae □ lesions □ purple
hissing or shrill as in asthma, striae □ tense, glistening skin (for ascites) □ dilated veins
quality COPD, bronchitis Configuration/Contour: □ flat □ globular □ protuberant
Rhonchi Low-pitched; have a Secretions in large □ scaphoid □ symmetrical □ asymmetrical
snoring quality airways Abdominal Movement: □ symmetrical □ asymmetrical
□ peristalsis □ aortic pulsations
* crackles is sometimes called rales
Umbilicus: □ sunken □ bulging □ hernia
Bowel Sounds: ________/min □ normoactive □
XIV. Heart
hyperactive □ hypoactive □ absent
Precordial Area: □ flat □ bulging
Arterial Bruit: □absent □present (○aortic ○iliac ○ renal)
□ normodynamic □ hyperdynamic □ tenderness
Friction Rub: □ absent □ present
PMI at _______________________________ □ pulsation
Percussion: Tympanitic at ________________________
□ displaced (○ laterally ○ lower) □ heave □ thrill
Dull at _____________________________
Aortic area at _______________________________________
Fluid Wave: □ absent □ present
□ pulsation □ heave □ thrill
Shifting Dullness: □ absent □ present
Pulmonic area at _____________________________________
Liver: □ non-palpable □ enlarged □ smooth border □
□ pulsation □ heave □ thrill
nodular □ hard □ tender □ non-tender
Tricuspid area at _____________________________________
Spleen: □ non-palpable □enlarged □tender □ non-tender
□ pulsation □ heave □ thrill
Bladder: □ non-palpable □ distended
Apical area at _______________________________________
Others: □ muscle guarding □ direct tenderness
□ pulsation □ heave □ thrill
□ rebound tenderness □ masses: _________________
Heart Sounds: □ distinct □ faint; S1__S2@base S1__S2@apex
CVA: □ tender □ non-tender Abdominal Reflexes:
Extra heart sounds: □ S3 □S4 R L
Jugular Vein: □ not visible □ distended Upper (T8, T9, T10)
Jugular Venous Pressure*: ____cm □ elevated □ not elevated Lower (T10,T11,T12)
XVII. Back and Extremities Upper Extremity Reflexes Grading Muscle Strength:
Spine: □ straight □ curved □ kyphosis □ scoliosis □ lordosis R L 0 0% of normal strength; complete paralysis
Joints: □ non-tender □ tender □ redness □ warm □ swelling Biceps (C5,C6) 1 10% of normal strength; no movement, contraction
□ crepitation □ nodules Triceps (C6,C7) of muscle is palpable and visible
ROM: □ move smoothly □ full □ decresed at _______________ Brachioradialis (C5,C6) 2 25% of normal strength; full muscle movement
Muscles: □ equal in size □ unequal in size □ atrophy Lower Extremity Reflexes against gravity, with support
□ contractures □ tremors □ firm/tonic □ atonic R L 3 50% of normal strength; normal movement against
□ foot drop Knee (L2,L3,L4) gravity
Movement: □ smooth □ coordinated □ flaccid □ spastic Ankle (S1) 4 75% of normal strength; normal full movement
Stength: □ equal □ unequal (GRADE: __________________) Plantar (L5,S1) against gravity and against minimal resistance
Peripheral pulses: □ symmetrical □ regular □ warm □ absent
Ankle Clonus
□ faint □ weak (W) □ strong (S) □ bounding (B) 5 100% of normal strength; normal full movement
Pos.
Carotid Brachial Radial Femoral Popliteal
TIb.
Pedal Legend: against gravity and against full resistance
R 0 + ++ +++ ++++
L No hypoactive Normal more active hyperactive XVI. Ano-Genital
reflex than normal FEMALE:
□ Brudzinski □ Kernig □ Nuchal rigidity □ Babinski Pubic Hair: □ kinky □ inverse triangle □ scant □ extended
Muscle R L to abdomen □ parasites □ lesions
Sternocleidomastoid Labia: □ symmetrical □ asymmetrical □ pinkish □
Trapezius discoloration
Deltoid Orifice: □ same color as surrounding tissue □
Biceps discoloration □ inflammation □ swelling □ discharge □
Triceps lesions
Wrist & Finger muscles Clitoris: _______cm
Grip strength MALE:
Hip muscles Pubic Hair: □ triangular distribution □ extending to
abdomen scant □ absent □ others: ________________
Hip abduction
Penis: □ intact skin □ slightly wrinkled □ wrinkled □
Hip adduction
smegma □ swelling □ inflammation □ nodules □ lesions
Hamstrings
□ tenderness □ immobility □ smooth/semifirm
Quadriceps Meatus: □ pinkish □ discoloration □
Muscle of ankles and feet discharge:______________
Scrotum: □ symmetrical □ asymmetrical □ marked
Handedness: □ Right □ Left asymmetry □ discoloration □ tightening of skin □ darker in
Joints: □ redness □ warmth □ crepitation color □ enlarged □ nodules □ lesions □ non-tender □
□ swelling at ________________________________________ tender
□ Tenderness at _____________________________________ BOTH:
□ full ROM Lymph Nodes:□ non-palpable □ swelling □ non-tender □
□ decreased ROM at _________________________________ tender
SENSATION AREA FINDINGS Muscle: □ size equal □ atrophy at _______________________ Femoral Hernia: □ absent □ present
Light Touch □ Tone normal □ hypertonic □ flaccid □ fasciculation □ tics Inguinal Hernia: □ absent □ present
(forehead, □ tremors □ strength equal Anus: □ intact skin □ lesions □ tender □ non-tender
cheek, hand, □ weakness at ______________________________________ RectalWall:□ smooth □ non-tender □ tender □ nodular □
lower arm, □ paralysis at _______________________________________ lesions
abdomen, foot, Leg shortening: □ Absent □ Present
lower leg) Trendelenburg’s sign: □ Negative □ Positive Compiled by: JRRafael
* Use cotton ball to tickle with eyes closed 2009-56972
UPCN Class 2013