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PHYSICAL EXAMINATION
B.Sc NURSING
GENERAL APPEARANCE:
VITAL SIGNS :
Temperature :
Pulse :
Respiration :
Blood pressure :
MEASUREMENTS:
Height :
Weight :
Colour and vascularity : Pink / brown /flushed / pallor/ cyanosed / jaundiced / brown /
pigmentation
generalized edema
Integrity : Intact/ lesions/ birth marks / moles/ scars/ rashes
/lumps
EYES
accommodation )
EARS
Pinnae-size/shape : Large/small/symmetry
NOSE
Septum : Midline/deviated/perforated
Patency : Patent/obstructed
Sinuses : Tender/non-tender
Teeth : colour/stained/carries/alignment/dentures
Gums : Pink/swollen/bleeding/gingivitis/ulcerated/spongy
Tongue : Dry/whitecoated/fissures/crackled/bluish/microglossia/
Macroglossia/ glossitis/halitosis
Tonsils :Enlarged/redness/dysphagia/
Uvula-mobile/midline/gag reflex
NECK
Thyroid :Palpable/nodules/tenderness
Trachea :Midline/deviated
CHEST:
Size/shape/symmetry/nipple/discharges/retractions/discharges/nodules/lumps/pain/trauma/
history of breast disease/ surgery
Abdomen :
GENITALIA
ANUS/RECTUM
:Hemorrhoids/inflammation/lesions/fissures/skin tags/rectocele/patency
BACK :
Lesions : Rashes/lesions
ROM :Possible/limited
EXTREMITIES :
RESPIRATORY SYSTEM:
: Rhythm- regular/irregular
Palpation : Soft/firm/hard/tenderness/organomegaly/hernia
RENAL SYSTEM
Palpation ; tenderness/palpable
Inspection : size, symmetry, shape, edema. deformity, prosthesis gait, ROM of each
reflexes
REPRODUCTIVE SYSTEM:
cystocele/rectocele
Male : Phimosis/priapisim/epispadiasis/hypospadiasis/hydrocele/hernia
GCS (0-15)
RESPONSE SCORE
EYE OPENING Spontaneously 4
To command 3
To pain 2
No response 1
MOTOR RESPONSE Obeys commands 6
Localizes pain 5
Flexion withdrawal 4
Flexion 3
Extension 2
No response 1
VERBAL RESPONSE Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
TOTAL 15
GRADE DESCRIPTION
5/5 Full range of motion against gravity with extreme resistance
4/5 Full range of motion against gravity with some resistance
3/5 Full range of motion against gravity with no resistance
2/5 Full range of motion with gravity eliminated
1/5 Slight contraction visible
0/5 No movements
Sensory examination
Response to touch
Response to pain and temperature
propioception
Reflexes:superficial &deep (abdominal, Achilles, corneal, biceps, triceps, patellar, plantar,
babinski reflex)