PHYSICAL EXAMINATION Dev’t □ endomorph □ mesomorph □ ectomorph

Date:________________ □ well □ fair □ poor

□ looks accdg. To age □ looks younger / older
General Information Nutrition □ well-nourished □ obese □ cachexic
Name: Emotional □ calm □ worried □ restless □ tense
Ward & Bed #: State □ others: _________________________
Address: Gait □ coordinated □ uncoordinated □ staggering
Med. Dx: □ shuffling □ stumbling □ unable to walk alone
Age/Sex: □ w/ assistive devices: ___________________

Vital Signs and Anthropometric Measurements Skin (use body sketch to note lesions)
T Oral / axillary / rectal General Color □ pallor □ jaundice □ flushing □ cyanosis
BP Sitting / lying / standing [R / L] [arm / leg] Temperature □ cold □ slightly warm □ warm (local / systemic)
PR Regular / irregular Site? Skin Tone □ light □ fair □ dark □ vitiligo
HR Regular / irregular Texture □ smooth □ rough □ easily broken □ others:
RR Regular / irregular Turgor □ immediate recoil □ tenting
Height Weight Moisture □ very dry □ sweaty □ oily □ moist in skin folds
Waist Hip Hygiene □ generally clean □ stains _______
BMI WHR Lesions Name
Wrist MUAC □ macule (<1 cm) □ petechiae
□ patch (>1 cm) □ purpura
General Survey □ papule (<0.5 cm) □ ecchymosis
LOC □ conscious □ drowsy □ plaque (>0.5 cm) □ angioma
□ stuporous □ comatose: Glasgow ___ □ nodule (0.5 – 1-2 cm) □ telangiectasia
Coherence □ coherent □ incoherent □ tumor (>1 to 2 cm) □ varicose veins
Orientation □ oriented □ disoriented to: time/person/place □ vesicle / blister (<1 cm) □ xanthelasma
General □ signs of distress □ bullae (>1 cm) □ excoriation
Appearance □ cardiorespiratory □ pustule / acne □ maceration
□ in pain (use body sketch to locate pain) □ cornedo “blackhead” □ ulcer: grade ___
□ anxious □ nevus “mole” □ fissure
□ wheal □ scar
□ chancre □ keloid
□ fissure □ lichenification
□ stoma □ crusts
□ xerosis (dry, scaly) □ skin cancer
Edema □ non-pitting □ pitting: grading ___
□ pedal edema[R / L] Grade: 1+ 2+ 3+ 4+
Pressure Ulcer Location and Size Stage I II III IV
Vascular Site/s: □ inflammation □ bruising
Insertions □ infiltration □ bleeding
Stoma / Site/s: □ redness □ pallor
Drainage □ purulent □ dry □ wet

Head
Configuration □ normocephalic □ masses _________
□ skull deformation □ depressions _________
Hair □ fine □ coarse □ dry □ breaks easily □ color ______
□ normal distribution □ bald spot □ alopecia
Scalp □ clean □ dandruff □ lice □ lesions
Eyes
Eyelids □ symmetrical □ edema/swelling [R / L] □ ptosis [R / L]
□ entropion □ ectropion
Periorbital □ edema □ sunken □ discoloration
Region □ xanthelasma □ lesions _____________
Conjunctiva □ pinkish □ pale □ lesion □ discharge □ hemorrhage
Sclera □ anicteric □ subicteric □ icteric □ hemorrhage
Cornea & Lens □ smooth □ clear □ lesions □ opacity □ arcus senilis
Pupil Size □ equal □ unequal R ___mm L ___mm
Reaction to L □ brisk □ sluggish □ fixed
Light R □ brisk □ sluggish □ fixed
Accommodxn □ uniform □ unequal
Convergence □ uniform □ unequal
Visual Acuity □ able to read newsprint with __ font size at __ distance with [R / L / both eyes]
□ grossly normal □ wears glasses / contact lenses
EOM □ coordinated □ uncoordinated
Eyebrows Hair distribution: □ thin □ thick □ lesions
Lacrimal Duct □ easy tearing □ tenderness □ discharge □ inflammation

Nose
Nasolabial Fold □ symmetrical □ shallow [R / L]
Septum □ midline □ deviated □ perforated □ polyps
Mucosa □ pinkish □ pale □ reddish Neck
Discharge □ serous □ purulent □ mucoid □ bloody Trachea □ midline □ deviation [R /L]
Patency □ both patent □ obstructed [R / L] □ masses / lesions __________________ Lymph Nodes □ nonpalpable □ palpable □ enlarged □ tender
Sense of Smell □ able to smell alcohol through each nostril Thyroid □ nonpalpable □ enlarged: □ unilateral □ bilateral
□ not able to smell alcohol through [R / L] nostril □ discrete nodules □ firmly attached □ freely mobile
Sinuses Frontal □ tender □ nontender □ transilluminated Others □ normal ROM □ neck rigidity
Maxillary □ tender □ nontender □ transilluminated □ NVE at ____
Oxygen Support □ cannula □ mask _____________ □ rate: ____________ □ masses: size _______ shape _______

Ears
External Pinnae □ normoset □ symmetrical □ tenderness □ gross abnormalities __________ Chest and Lungs
External Canal □ impacted cerumen □ lesions _____________ Inspiration
Discharge □ foul-smelling □ serous □ purulent □ mucoid Expiration Ratio
□ color __________ □ amount _____________ Inspection □ pectus excavatum (hollowed chest) □ pectus carinatum (pigeon chest)
Gross Hearing Whisper test: □ normal □ hearing problem [R L] Breathing □ eupnea □ hyperpnea □ tachypnea □ dyspnea
Pattern □ use of accessory muscles _______________
Mouth and Pharnyx Shape of Chest APL Ratio: ___AP ___L □ barrel □ funnel □ pigeon □ others__________
Lips □ pallor □ cyanosis □ dryness / cracks Chest Expansion □ symmetrical □ decrease / lag [R / L]
□ lesions _________ □ mouth sore □ cleft Tactile Fremitus □ symmetrical □ inc / dec at [R / L]
Tongue □ midline □ deviated [R /L] □ atrophy Breath Sounds □ vesicular over: □ most of lungs □ [R / L] □ I _ E
□ fasciculations □ lesions □ color □ pitch: low / medium / high □ absent
Teeth □ complete □ missing □ bronchovesicular over: □ 1st& 2nd ICS □ I _ E
□ caries □ dentures □ braces/retainers □ intrascapular □ pitch: low / medium / high
Gums □ pinkish □ pale □ bleeding □ tenderness □ bronchial over: □ manubrium □ lobar pneumonia
Mucosa Oral: □ pinkish □ pale □ cyanotic □ I _ E □ pitch: low / medium / high
Pharynx: □ dull red □ pale □ cyanotic □ exudates: color __________ Adventitious □ rhonchi over ______________ □ wheezes over ______________
Palate □ lesion _________ □ cleft Sounds □ crackles / rales □ pleural friction rub □ stridor
Uvula □ midline □ deviated [R / L] Percussion □ resonant [R / L] □ dull [R / L] over __________
□ hyperresonant [R / L] over __________
Tonsils □ inflammation: grade _____
Ventilator □ Bennett MA-1 □ Galileo □ Raphael
Speech □ intact □ slurred □ aphasic □ others ___________________
Sputum □ color _________ □ amount __________ □ others ____________
Heart Episiotomy □ redness □ edema □ ecchymosis □ discharge □ approximation of the edges
Pericordial Area □ flat □ bulging □ normodynamic □ hyperdynamic □ tenderness □ heaves / thrills Homan’s Sign □ pain in calf when pressure is applied on knee while flexing foot
PMI at _______________ Catheterization
Jugular Veins □ normal □ distension: lying ___degrees, ___cm
Carotid Arteries □ easily palpable □ diminution Postpartum Emotional Status
Heart Sounds □ faint □ distinct □ S3 □ S4 S1__S2 at base; S1__S2 at apex Does the client appear
□ murmur, grade __ best heard at ____________ dependent or independent?
Percussion □ cardiac dullness from ___ to ___ ICS
Is she elated or despondent?
Breast and Axillae
Symmetry □ equal □ unequal □ engorgement What does she say about
Contour □ masses _________ [R / L] □ dimpling _________ [R / L] family?
Skin □ redness □ edema □ lesions _______________
□ vein distention □ warm □ cool
Tenderness □ tender at ___________ □ nontender Non-verbal responses noted
Nipple and □ inversion □ flattening / retraction □ deviation to [R /L]
Areola □ edema □ milk production

Abdomen Genito-Urinary System (Male)

Skin □ dilated veins □ striae □ scar _______________ Penis □ discharge: □ purulent □ bloody □ foul smelling
□ rashes □ lesions _______________________ □ nodular growth □ lesions ______________
Umbilicus □ sunken □ bulging □ hernia □ tenderness □epispadia □hypospadia
Configuration □ flat □ globular □ protuberant □ scaphoid □ symmetrical □ asymmetrical Scrotum □ equal □ tenderness □ enlargement [R / L]
Bowel Sounds □ normoactive ____/min □ hyperactive ____/min □ undescended [R / L]
□ hypoactive ____/min □ absent □ dull □ medium □ loud □ nodules / growths / lesions at ____________
Bruit □ absent □ present over _____________ Others □ hernia □ hydrocele
Percussion □ tympanitic □ hyperresonant over ___________
□ dull over ___________ □ fluid wave □ shifting dullness Back and Extremities
Palpation □ muscle guarding □ liver: □ tenderness Peripheral □ symmetrical □ regular □ warm □ absent □ faint
□ CVA tenderness□ rebound tenderness Pulses □ weak □ strong □ bounding
□ liver span ____cm □ splenic dullness Nails □ pink □ pale □ cyanosis □ inflammation
□ aorta: □ palpable □ well-defined mass □ clubbing □ blanching
Psoas Sign □ pain in lifting thigh when resistance is applied on knee Joints □ redness □ warmth □ crepitation
Obturator Sign □ pain when moving bent knee left and right □ swelling at _____________
Fetus LMP ___wks □ tenderness at _____________
Fundic Height ____cm □ full ROM
Fetal Position and Lie: [R / L] ______________ □ decreased ROM at _____________
Fetal Presentation ____________ □ ballottement Muscle □ size equal □ atrophy at ______________
FHR: ______beats/min at _________ □ normal trone□ hypertonic □ flaccid
Uterus (post- □ ___ fingerbreadth/s below umbilicus □ fasciculation □ tics □ tremors
partum) □ firm □ soft □ strength equal: score 0 1 2 3 4 5
Bladder (post- □ distention □ weakness at _____________
partum) □ paralysis at _____________
Fine Motor □ finger-to-nose: □ smooth & accurate □ fail
Genito-Urinary System (Female) □ heel-to-shin: □ smooth & accurate □ fail
Labia □ symmetrical □ asymmetrical □ lesions ________________ □ finger movement: □ smooth & accurate □ fail
□ pinkish □ discoloration □edema Reflexes □ patellar: grade 0 1 2 3 4
Vaginal Orifice □ discharge: □ purulent □ bloody □ foul smelling □ Achilles: grade 0 1 2 3 4
Others □ swelling □ lumps or nodules at ____________ Spine □ midline □ kyphosis □lordosis□ scoliosis
Hemorrhoids
Lochia (post- □ rubra: □ red □ bloody □ ___ pads/day □ small clots □ large clots
partum) □ serosa: □ pink/brown-tinged □ serosanguinous □ ___ pads/day □ clots
□ alba: □ yellowish white □ serosanguinous □ ___ pads/day
 GRADATION OF MURMURS BUBBLEHE Guide (POSTPARTUM)
GRADE 1 VERY FAINT, MAY NOT BE HEARD IN ALL POSITIONS
GRADE 2 QUIET, BUT HEARD IMMEDIATELY AFTER PLACING THE STETHOSCOPE
GRADE 3 MODERATELY LOUD Preparation: □ wash hands □ explain procedure □ empty bladder □ supine position
GRADE 4 LOUD WITH PALPABLE THRILL INSTRUCTIONS SPECIAL POINTS TO NOTE
GRADE 5 VERY LOUD WITH THRILL, HEARD WHEN STETHOSCPOPE IS PARTLY OFF THE CHESS Breast
GRADE 6 VERY LOUD WITH THRILL, HEARD WHEN STETHOSCPOPE IS ENTIRELY OFF THE CHESS □ gently palpate each breast □ equal □ unequal □ engorgement
□ nodules: ducts may have not been emptied at □ masses _________ [R / L]
GRADATION OF PULSES last breastfeeding □ dimpling _________ [R / L]
0 ABSENT, UNABLE TO PALPATE □ stroke downward towards nipple, then gently □ redness □ edema
1+ DIMINISHED, WEAKER THAN EXPECTED release milk □ lesions _______________
2+ BRISK, EXPECTED, NORMAL □ if nodules remain, notify doctor □ vein distention □ warm □ cool
3+ BOUNDING □ explain process of milk production □ tender at ___________ □ nontender
□ explain what to do if there is engorgement □ inversion □ flattening / retraction
GRADATION OF EDEMA □ teach self breast examination □ deviation to [R /L]
□ answer any questions client may ask □ edema □ milk production
1+ SLIGHTLY PITTING/2MM, DISAPPEARS RAPIDLY
Uterus
2+ SOMEWHAT DEEPER PIT/4MM, DISAPPEARS IN 10-15 SECONDS
□ palpate □ ___ fingerbreadth/s below umbilicus
3+ DEEP PIT/6 M MM, MAY LAST > 1 MIN, DEPENDENT EXTREMITY SWOLLEN
□ have patient feel uterus □ explain involution □ firm □ soft
4+ VERY DEEP PIT/8MM, LASTS 2 TO 5 MIN, DEPENDENT EXTREMITY GROSSLY DISTORTED
□ if not involuting properly, check for infection,
fibroids, and lack of tone
GRADATION OF MUSCLES
□ fundic height
GRADE 0 NO MUSCULAR CONTRACTION DETECTED
Bladder
GRADE 1 A BARELY DETECTABLE FLICKER OR TRACE OF CONTRACTION
□ inspect □ palpate □ distention □ displacement
GRADE 2 ACTIVE MOVEMENT OF THE BODY PART WITH GRAVITY ELIMINATED □ catheterization, if ordered □ urine sample □ catheterization
GRADE 3 ACTIVE MOVEMENT AGAINST GRAVITY □ teach perineal care □ urinates ___ times a day
GRADE 4 ACTIVE MOVEMENT AGAINST GRAVITY AND SOME RESISTANCE Bowel
GRADE 5 ACTIVE MOVEMENT AGAINST FULL RESISTANCE WITHOUT EVIDENT FATIGUE/ NORMAL □ question about bowel movements □ defecates ___ times a day
MUSCLE STRENGTH □ encourage fiber-rich foods and hydration □ fluid intake ___ glasses of water a day
Lochia
OTHER NOTES: □ inform mother about changes to expect in lochia □ rubra: □ red □ bloody □ ___ pads/day
and when it should cease (rubra: 1-3 days; serosa: □ small clots □ large clots
3-10 days; alba: 10-14 days but not abnormal to □ serosa: □ pink/brown-tinged □ serosanguinous
last longer) □ ___ pads/day □ clots
□ inform when her next menstrual period will □ alba: □ yellowish white □ serosanguinous
SIGNIFICANT PE FINDINGS FROM CHART REVIEW: begin and when she can resume sexual relations □ ___ pads/day
□ discuss family planning
Episiotomy
□ inspect with flashlight for better visibility □ redness □ edema □ ecchymosis
□ rectal area: hemorrhoids □ discharge □ approximation of the edges
□ reassure patient and answer questions
Homan’s Sign
□ pain in the calf and popliteal area on passive
dorsiflexion of the foot
Emotional Status
□ notice and evaluate emotional status □ postpartum blues
□ explain to mother and family that she may cry □ postpartum psychosis
easily for a while, emotions may shift from high to
low □ taking-in (2-3 days)
□ these are normal and caused by hormonal □ taking hold
changes in her body and realization of new □ letting go
responsibilities that accompany each child’s birth