DE LA SALLE HEALTH SCIENCES INSTITUTE

City of Dasmariñas, Cavite

COLLEGE OF MEDICINE

PHYSICAL DIAGNOSIS

(Revised Appendix 10 of Physical Diagnosis Ward Work Manual 2017)

NAME:
PRECEPTOR:

HISTORY TAKING:
Done Done Not Remarks
Improperly Done
I. Starting the Interview:

1. Introduced him/himself by saying his/her name

2. Informed the patient of the purpose of the
interview
3. Put the patient at ease

II. Interview proper:

1. Established eye contact with the patient

2. Asked the necessary data that they need to elicit

3. Used open-ended, leading questions when the

situation called for it
4. Were able to catch cues to follow-up
5. Showed interest and concern for the feelings of
the patient
6. Demonstrated organization, coherence and
control of the interview

III. Closure:

1. Gave a periodic summary before moving on to other

problems or other parts of the history

2. Gave a closing statement and a chance for the patient to

conform or disagree with data gathered

3. Thanked the patient for showing the necessary

information
 Done Done Not Remarks
Improperly Done
I. GENERAL DATA
1. Patient’s Name
2. Age
3. Sex
4. Marriage Status
5. Nationality and Race
6. Religion
7. Occupation
8. Place of Birth
9. Residence
10. Number/Time of Admission
II. CHIEF COMPLAINT
III. HISTORY OF PRESENT ILLNESS:
A. Onset
B. Continuity / Intermittency
C. Character
D. Location and Radiation
E. Progression / Course
F. Aggravating Factors
G. Relieving Factors
H. Associated Symptoms
I. Risk Factors
* Past Medical History
a. History of similar illness
b. Other illnesses
* Family History
a. History of similar illness
b. Other illnesses
* Personal and Social History
a. Diet
b. Smoker/Alcohol intake
c. Employment
d. Lifestyle
J. Review of System
a. General Health
b. Integument
c. Hematopoietic
d. Eyes
e. Ears
f. Upper Respiratory Tract
g. Mouth
h. Breasts
i. Respiratory Tract
j. Cardiovascular System
k. Gastrointestinal
l. Nutrition
m. Urinary Tract
n. Genitals/ Sexuals
o. Menses/ Obstetrical
p. Musculoskeletal
q. Nervous System
r. Endocrine System
s. Allergies
t. Emotional/ Behavioral
 Physical Examination of the EAR, NOSE, THROAT- HEAD & NECK

DONE DONE NOT Remarks

IMPROPERLY DONE
1.Use of head mirror:
Able to focus andilluminate desired ENT area
2. Assessment of the Ear:
Performs inspection and palpation of the
external ear and mastoid area.does
Otoscopy properly and states/records
findings
3. Assessment of Hearing:
Performs Weber and Rinne, Schwabach tests
with correct instructions given to patient,
states the results and conclusions.
4. Assessment of the nose:
Inspects anterior nasalcavity and performs
test for nasal patency, perform posterior
rhinoscopy.

*odorant testing
5. Assessment of the oral cavity and
oropharynx:
Using tongue blade on anterior portion of
tonguewhile inside the mouth, inspects the
contents of theoral cavity (tongue, teeth,
gums, buccal mucosa,Stensen’s and
Wharton’s duct, hard palate etc.) inspect
oropharynx (tonsils' size, one side at a
time,soft palate, post. Pharyngeal wall, soft
palate etc.) States/records findings

*Assessment of taste
6. Perform indirect mirror laryngoscopy:
Note position, mobility of vocal cords. Note
for masses, lesions, pooling of saliva.
7. Assessment of the Thyroid gland,
parotid,sub mandibular glands trachea,
carotids:
Inspects and palpates the thyroid gland, bi-
manually,one side at a time, from behind
and in front. Inspect and palpate the
parotid & sub mandibular glands, the
trachea if midline or deviated, palpate
the carotid one side at a time to avoid
Vaso-vagal reflex/bradycardia.
States/records findings.

*Identification of (e.g. landmarks and

triangles of the neck, cricoid).
8. Assessment of the cervical lymph
nodes: Inspects and palpates properly, one
side at a time, the cervical lymph nodes,
identifies the Sternocleidomastoid muscle
and names correctly at least 3(three)
lymph node groups palpated.
9. Palpation of The Facial Skeleton:
Inspects face for symmetry/deformity.
Palpates the facial bone (frontal, orbital
rims, zygoma, maxilla, asal bone, temporal
mandibular joints, zygomatic arch and
mandible)
 Physical Examination of the Eye

DONE DONE NOT Remarks

IMPROPERLY DONE
1. PERFORMS VISUAL ACUITY TESTING
a. Positions the patient 10ft from the
chart
b. Asks patient to cover one eye with
an opaque occluder or the palm of
the hand making sure no pressure is
applied to the eye.
c. Asks patient to read the Snellen
chart (top to bottom) until the line
in which patient is able to correctly
read the majority of the optotypes.
i. If the first line cannot be
read, asks the patient to
move 3 feet closer to the
chart until the biggest
optotype is read correctly.
ii. If at 3 feet the first
optotype cannot be
visualized, visual acuity is
assessed using counting
fingers first at 3, 2, and
1fott distance.
iii. If vision is less than
counting fingers, evaluates
if patient can sense hand
motion or not and
evaluates light projection
by flashing a light on the 4
quadrants and asks the
patient to localize the
direction of light.
iv. If VA is less than light
projection, evaluates for
presence or absence of
light perception.
d. Performs the pinhole test if patient
is unable to read the 20/20 line.
(bonus item if patient can readup to
the 20/20 line)
e. Performs near vision test using
Jaeger chart at 14 inches away
from the patient (both eyes open)
f. Reports/Records findings
2. PERFORMS GROSS EXAMINATION OF
THE EYE
a. Examines the patient’s eye under
good illumination or with the aid of
a penlight
b. Note’s eyelid position in relation
to the eyeball (The upper lid
margin should cover about 2mm of
the upper border of the cornea
while the lower lid margin should be
resting just below the inferior
border of the cornea). Inspects
for presence of lesions and
swelling, lash direction and crusting.
Palpates adnexa for masses.
c. Everts upper lid (optional) and
manually retracts lower lids to
inspect for palpebral conjunctival
hyperemia, discharge, lesions.
Retract the upper lid and describes
bulbar conjunctiva, notes for
presence of hyperemia and lesions.
d. Inspects corneal light reflex by
shining a light onto the patient’s eye
2-3 feet away, instructing the
 patient to look at it. Notes if light
reflections fall on both corneas at
similar positions.

e. Describes cornea and presence of

opacities, lesions, and foreign body.
f. Inspects size, shape, and equality of
pupils. Test for pupillary reaction to
light (direct and consensual light
reflex)
g. Reports/Records findings

3. PERFORMS:
EOM’s testing
a. Positions self at 3 feet in front of the
patient
b. Performs duction test by asking the
patient to cover one eye
c. Asks the patient to follow the
examiner’s finger, positioned an
arm’s length away at eye level,
extending the arm to ensure full
range of motion in the 6 cardinal
directions of gaze.
d. Performs version test, both eyes
simultaneously (follow the same
procedure as letter c)
e. Reports/Records finding
Tonometry
a. Asks patient to look down to ensure
that you are pressing on the eyelids
above the sclera.
b. Performs palpation tonometry by
using one index finger to press
gently while the other index finger
feels for the rebound adjacent to it
c. The rest of the fingers should lay on
the forehead or temporal area.
d. Estimates the firmness or softness
e. Reports/Records findings
4. PERFORMS FUNDUSCOPY
a. Performs examination in a dimly lit
room and the patient should be in
a comfortable sitting or standing
position. Asks the patient to look
at a distance.
b. Holds the ophthalmoscope
correctly. Checks the light source
and switches to the middle or
largest diameter of the beam.
Adjusts lens power to correct for
any errors of refraction.
c. Examines patient's right eye using
right hand and right eye.
d. Likewise, examines patient’s left
eye using left hand and left eye.
e. Directs the ophthalmoscope light
into the eye of the patient to
detect red-orange reflex (ROR) and
moves closer to the patient at a 15-
degree angle temporal to the
patient’s line of sight until retina is
visible.
f. Adjusts the focusing wheel to bring
the retina into focus. Examines the
optic disc & cup, retinal vessels,
retinal background, and the macula.
Determine cup: disc (CD) ratio,
arterio:venous (AV) ratio, presence
of foveal light reflex and
 abnormalities such as hemorrhages
and exudates.
g. Reports/Records findings
 PHYSICAL EXAMINATION SKILLS FOR ABDOMEN and SPECIAL MANEUVERS

DONE DONE NOT Remarks

IMPROPERLY DONE
1. Prepares patient for the examination (re:
consent, position, cover/ draping)
2. Performs INSPECTION to ascertain
and/or determine the
presence/absence of:
a. Contour
b. Symmetry
c. Lesions
d. Scars
e. Discolorations
f. Visible mass
g. Visible peristalsis
h. Visible pulsations
3. Performs AUSCULTATION
a. Does auscultation ahead of
palpation/percussion
b. Listen for bowel sounds in each
quadrant/ region
c. Reports frequency/min
d. Reports character/ pitch of bowel
sounds heard
4. Performs PALPATION
a. Determines consistency (soft, firm)
by light palpation
b. Palpates quadrant(s) without
reported pain (light then deep
palpation) first
c. Examines tender areas last for… direct
tenderness, rebound tenderness, if
necessary
d. does modified/ special
techniques of palpation
▪ single handed
▪ reinforced
▪ bimanual
▪ ballottement
a. Performs Palpation of Different
Abdominal Organs (or mass, if
b. any)
▪ Liver (RUQ Palpation)
▪ Hooking Technique (Liver)
▪ Spleen
▪ (R) Kidney
▪ (L) Kidney
▪ Aorta, if applicable
▪ Mass (if any)
5. Performs PERCUSSION
a. Percusses entire abdomen 1st for
b. general distribution of tympany
c. Assesses liver span (for
hepatomegaly):
▪ determines lower border
(percussing tympany to
dullness or palpated for liver
edge)
▪ determines upper border
(percussing resonance to
dullness)
▪ measures vertical liver
span
 a. Assesses Traube’s space and Castell’s
sign (for splenomegaly)
b. Assesses presence of mass/
organomegaly (if present)
7. Performs SPECIAL MANEUVERS for
specific conditions
a. Fluid wave – stand on patient’s right
side. Place the ulnar edge of another
examiner’s hand or the patient’s own
hand firmly on the abdomen in the
midline. Place your hand on the patient’s
right flank. With your right hand, reach
across the abdomen and give the left
flank a firm strike/tap.
b. Shifting Dullness – with patient
supine, performs percussion over the top
of the abdomen down to the side of the
abdomen. Marks both initial levels of
tympany and dullness. Turns patient into
the right side and does percussion from
on the upper side of the abdomen and
moves downward. Notes the change
from tympany to dullness. With the
presence of fluid, the level of dullness is
higher upward toward the umbilicus.
c. Succussion splash (gastric
outlet obstruction) – shakes the
patient’s abdomen with the
stethoscope bell placed in the LUQ. A
very loud splash is elicited if positive
d. Murphy’s sign (inflammation of
gallbladder) – insinuates fingers
under the patients’ liver border (right
subcostal margin). Ask patient to inspire
deeply. There is an arrest of patient’s
inspiration if positive
e. Rovsing’s sign (inflamed
appendix) – press deeply and evenly
in the left lower quadrant. Pain is felt by
the patient in the right lower quadrant
f. Obturator sign (inflamed
appendix) – with the patient supine,
lifts the right leg flexing at the hip and
90 degrees at the knee. Holds the
patient’s ankle and rotate the leg
internally and externally. (+) RLQ pain is
positive
g. Psoas sign (inflamed appendix) –
with patient supine, lifts the right leg
straight up flexing at the hip. Pushes
down over the lower part of the right
thigh as the patient tries to hold the leg
up. (+) RLQ pain if positive
h. CVA tenderness – place one hand
over the 12th rib at the costovertebral
angle at the back. Thump that hand
with the ulnar edge of your other fist.
Patient feels pain if finding is
positive.
 PHYSICAL EXAMINATION SKILLS FOR MSK

DONE DONE NOT DONE Remarks

IMPROPERLY
Gait Assessment
a. Observes patient walking forwards
for a few meters, turning and
walking back again
b. Recognizes abnormalities of the
different phases – heel strike, stance
phase, toe off and swing phases
c. Looks for abnormalities of
movements of the arm
Spine Assessment
a. TMJ Assessment
i. Identifies anatomical
landmarks on the TMJ
(redness, cyanosis, pallor,
loss of hair, lesions of the
nails and of the skin in
general; symmetry; muscle
bulk; deformities; swelling;
masses; edema; involuntary
or abnormal movements)
ii. Places the tips of your
index fingers just in front of
the tragus of each ear and
ask the patient to open his
or her mouth. Snapping or
clicking may be felt or
heard in normal people
iii. Examines ROM
b. Spine
i. Views patient from the
back, side and front looking
for any abnormalities in
particular of posture and
symmetry
ii. Identifies anatomical
landmarks on the spine
(redness, cyanosis, pallor,
loss of hair, lesions of the
nails and of the skin in
general; symmetry; muscle
bulk; deformities; swelling;
masses; edema; involuntary
or abnormal movements)
iii. Examines for tenderness by
applying pressure in the
midpoint of each
supraspinatus and rolling
an overlying skin fold
iv. From a sitting or standing
position, palpates the
spinous processes of each
vertebra with your thumb
v. Palpates over the sacroiliac
joint
vi. Percusses the spine for
tenderness by thumping
(not too roughly) with the
ulnar surface of your fist
vii. Palpates the paravertebral
muscles
viii. Examines ROM (include
manual muscle strength
testing of neck flexors and
extensors) - Asks the
patient to flex the neck
laterally to each side. Places
 several fingers on lumbar
spinous processes and ask
them to bend forward and
attempt to touch their toes
whilst standing with the
legs fully extended,
observing, and feeling for
normal movement
Arms
• Asks the patient to place both hands
behind their head with elbows right
back
• Asks the patient to straighten the
arms down the side of the body and
then inspect with elbows bent to 90o
with palms down and fingers
straight
• Asks the patient to turn hands over
and make a tight fist with each hand
• Asks the patient to place in turn the
tip of each finger onto the tip of the
thumb
• Squeezes the metacarpals from 2nd
to 5th
a. Shoulder
i. Identifies anatomical
landmarks (redness,
cyanosis, pallor, loss of hair,
lesions of the nails and of
the skin in general;
symmetry; muscle bulk;
deformities; swelling;
masses; edema; involuntary
or abnormal movements)
ii. With the patient sitting or
standing and the examiner
facing the patient, presses
the shoulder joint with the
thumb. Also check the
biceps brachii tendon at its
groove for tenderness
iii. Examines active and
passive ROM (include
manual muscle strength
testing of shoulder flexors,
extensors, abductors, and
adductors)
b. Elbow
i. Identifies anatomical
landmarks
ii. Supports the patient’s
forearm with your opposite
arm so that the elbow is
flexed 70 degrees
iii. Palpates the grooves
between the epicondyles
and the olecranon
iv. Examines active and
passive ROM (include
manual muscle strength
testing of elbow flexors and
extensors
c. Wrist
i. Identifies anatomical
landmarks
ii. Palpates the eight carpal
bones, the distal radius and
ulna on the lateral and
medial surfaces
iii. Palpates the groove of each
wrist joint with examiner’s
 thumbs on the dorsum of
the wrist joint and
examiner’s fingers beneath
it
iv. Examines active and
passive ROM of the wrist
(include manual muscle
strength testing of wrist
flexors and extensors)
d. Fingers
i. Palpates the medial and
lateral aspects of each DIP
and PIP joint between your
thumb and index finger
ii. Palpates each MCP is then
palpated by pressing the
dorsal aspect of the joint
with the examiner’s thumbs
and the ventral aspect by
the examiner’s forefingers
iii. Examines active and
passive ROM of the fingers
(include manual muscle
strength testing of finger
flexors and extensors
e. Upper Extremity Girth
i. From the bony point of
reference, extends the tape
measure up to the muscle
bulk, note the distance and
get the circumference at
this point (use the
acromion for the arm and
the lateral epicondyle for
the forearm)
Legs
• With the patient reclining on a
couch, flexes in turn each hip and
knee while holding and feeling the
knee
• Passively rotates the hip internally
• With the leg extended resting on the
couch, examines for tenderness or
swelling of the knee by pressing
down on the patella while cupping it
proximally
• Squeezes all the metatarsals and
finally inspect the soles of the feet
for callosities
a. Hips
i. Identifies anatomical
landmarks (redness,
cyanosis, pallor, loss of hair,
lesions of the nails and of
the skin in general;
symmetry; muscle bulk;
deformities; swelling;
masses; edema; involuntary
or abnormal movements)
ii. With the patient supine,
ask the patient to place the
heel of the leg being
examined on the opposite
knee
iii. Palpates along the inguinal
ligament, extending from
the ASIS to the pubic
tubercle
iv. Examines active and
passive ROM (include
manual muscle strength
 testing of hip flexors and
extensors)
b. Knee and Leg
i. Identifies anatomical
landmarks o Asks the
patient to sit on the edge of
the examining table with
the knees in flexion
ii. Palpates the femoral
condyles, patella and the
patellar tendon, the bursae
(prepatellar bursa, anserine
bursa found at the
posteromedial side of the
knee) and the popliteal
fossa
iii. Checks for bulge sign (for
minor effusions)
• With the knee extended,
places the left hand above
the knee and apply
pressure on the
suprapatellar pouch,
displacing, or “milking”
fluid downward
• Strokes downward on the
medial aspect of the knee
and apply pressure to force
fluid into the lateral area
• Taps the knee just behind
the lateral margin of the
patella with the right hand
iv. Examines active and
passive ROM (include
manual muscle strength
testing of knee flexors and
extensors
c. Ankle and Foot
i. Identifies anatomical
landmarks o With your
thumbs, palpates the
anterior aspect of each
ankle joint, the Achilles
tendon, and the heel.
Palpate the
metatarsophalangeal
joints
ii. Compresses the forefoot
between the thumb and
fingers
iii. Exerts pressure just
proximal to the heads of
the 1st and 5th
metatarsals
iv. Palpates the heads of the
5 metatarsals and the
grooves between them
with your thumb and
index finger
v. Places thumb on the
dorsum of the foot and
the index finger on the
plantar surface
vi. Examines active and
passive ROM (include
manual muscle strength
testing of ankle
dorsiflexors and plantar
 extensors)

d. Lower Extremity Girth

i. From the bony point of
reference, extends the
tape measure up to the
muscle bulk, note the
distance and get the
circumference at this
point (use the ASIS for
the thigh and the
superior border of
patella for the leg)
Special Maneuvers

a. Upper Extremity
i. Tinel’s
ii. Phalen’s
iii. Finkelstein’s
b. Lower Extremity
i. Anterior and posterior
drawer tests for the
cruciate ligaments
ii. Valgus/abduction stress
test and varus/adduction
stress test for the
collateral ligaments
iii. McMurray test for the
meniscus