Physical Examination

Date:________________ Moisture □ very dry □ sweaty □ oily □ moist in skin folds

Hygiene □ generally clean □ stains _______
General Information Lesions Name
Name: □ macule (<1 cm) □ petechiae
Ward & Bed #: □ patch (>1 cm) □ purpura
Address: □ papule (<0.5 cm) □ ecchymosis
Med. Dx: □ plaque (>0.5 cm) □ angioma
Age/Sex: □ nodule (0.5 – 1-2 cm) □ telangiectasia
□ tumor (>1 to 2 cm) □ varicose veins
Vital Signs and Anthropometric Measurements □ vesicle / blister (<1 cm) □ xanthelasma
T Oral / axillary / rectal □ bullae (>1 cm) □ excoriation
BP Sitting / lying / standing [R / L] [arm / leg] □ pustule / acne □ maceration
PR Regular / irregular Site? □ cornedo “blackhead” □ ulcer: grade ___
HR Regular / irregular □ nevus “mole” □ fissure
RR Regular / irregular □ wheal □ scar
□ chancre □ keloid
Height Weight
□ fissure □ lichenification
Waist Hip
□ stoma □ crusts
BMI WHR
□ xerosis (dry, scaly) □ skin cancer
Wrist MUAC
Edema □ non-pitting □ pitting: grading ___
□ pedal edema[R / L] Grade: 1+ 2+ 3+ 4+
General Survey
Pressure Ulcer Location and Size Stage I II III IV
LOC □ conscious □ drowsy
□ stuporous □ comatose: Glasgow ___
Encircle areas / draw
Coherence □ coherent □ incoherent
lesions on the anatomic
Orientation □ oriented □ disoriented to: time/person/place location to note shape,
General □ signs of distress symmetry, and size.
Appearanc □ cardiorespiratory
e □ in pain (use body sketch to locate pain)
□ anxious

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 □ arcussenilis
Dev’t □ endomorph □ mesomorph □ ectomorph
□ corneal reflex □ positive □ negative
□ well □ fair □ poor
Pupil Size □ equal □ unequal R ___mm L ___mm
□ looks accdg. To age □ looks younger / older
Reaction to L □ brisk □ sluggish □ fixed
Nutrition □ well-nourished □ obese □ cachexic
Light R □ brisk □ sluggish □ fixed
Emotional □ calm □ worried □ restless □ tense
Accommodxn □ uniform □ unequal
State □ others: _________________________
Convergence □ uniform □ unequal
Gait □ coordinated □ uncoordinated □ staggering
Visual Acuity □ able to read newsprint with __ font size at __ distance
□ shuffling □ stumbling □ unable to walk alone
with *R / L / both eyes+ □ grossly normal
□ w/ assistive devices: ___________________
□ wears glasses / contact lenses
□ intact peripheral visual fields
Skin
EOM □ coordinated □ uncoordinated
General Color □ pallor □ jaundice □ flushing □ cyanosis
Eyebrows Hair distribution: □ thin □ thick □ lesions
Temperature □ cold □ slightly warm □ warm (local / systemic)
Lacrimal Duct □ easy tearing □ tenderness □ discharge □ inflammation
Skin Tone □ light □ fair □ dark □ vitiligo
Texture □ smooth □ rough □ easily broken □ others:
Nose
Turgor
Nasolabial Fold □ symmetrical □ shallow *R / L+
 Physical Examination

Septum □ midline □ deviated □ perforated □ polyps Thyroid □ nonpalpable □ enlarged: □ unilateral □ bilateral
Mucosa □ pinkish □ pale □ reddish □ discrete nodules □ firmly attached □ freely mobile
Discharge □ serous □ purulent □ mucoid □ bloody Others □ normal ROM □ neck rigidity
Patency □ both patent □ obstructed *R / L+ □ NVE at ____
□ masses / lesions ______________________ □ masses: size _______ shape _______
Sense of Smell □ able to smell alcohol through each nostril
□ not able to smell alcohol through *R / L+ nostril Chest and Lungs
Sinuses Frontal □ tender □ nontender □ transilluminated Inspiration
Maxillary □ tender □ nontender □ transilluminated Expiration Ratio
Inpection □ pectus excavatum (hollowed chest)
Ears □ pectus carinatum (pigeon chest)
External Pinnae □ normoset □ symmetrical □ tenderness □ lesions
□ gross abnormalities ______________ Breathing □ eupnea □ hyperpnea □ tachypnea □ dyspnea
External Canal □ impacted cerumen □ lesions _____________ Pattern □ use of accessory muscles _______________
Discharge □ foul-smelling □ serous □ purulent □ mucoid Shape of Chest APL Ratio: ___AP ___L
□ color __________ □ amount _____________ □ barrel □ funnel □ pigeon □ others__________
Gross Hearing Whisper test: □ normal □ hearing problem *R L+ Chest Expansion □ symmetrical □ decrease / lag *R / L+
Weber □positive □ negative Tactile Fremitus □ symmetrical □ inc / dec at *R / L+
Test(lateralization) Vocal Fremitus □ bronchophony □ whispered pectoriloquy
Rinne Test □ air conduction bone conduction □ egophony
Breath Sounds □ vesicular over: □ most of lungs □ *R / L+ □ I _ E
□ pitch: low / medium / high □ absent
Mouth and Pharnyx □ bronchovesicular over: □ 1st& 2nd ICS □ I _ E
Lips □ pallor □ cyanosis □ dryness / cracks □ intrascapular □ pitch: low / medium / high
□ lesions _________ □ mouth sore □ cleft □ bronchial over: □ manubrium □ lobar pneumonia
Tongue □ midline □ deviated *R /L+ □ atrophy □ I _ E □ pitch: low / medium / high
□ fasciculations □ lesions □ color Adventitious □ rhonchi over
Teeth □ complete □ missing Sounds □ wheezes over
□ caries □ dentures □ braces/retainers □ crackles / rales
Gums □ pinkish □ pale □ bleeding □ tenderness □ pleural friction rub
Mucosa Oral: □ pinkish □ pale □ cyanotic □ stridor
Pharynx: □ dull red □ pale □ cyanotic Percussion □ resonant *R / L+ □ dull *R / L+ over __________
□ exudates: color ___________ □ hyperresonant *R / L+ over __________
Palate □ lesion _________ □ cleft Excursion □ diaphragmatic dullness at __________
Uvula □ midline □ deviated *R / L+ □ respiratory excursion around__________
Tonsils □ inflammation: grade _____ Ventilator □ Bennett MA-1 □ Galileo □ Raphael
Speech □ intact □ slurred □ aphasic
□ others ___________________ Heart
Sputum □ color ___________ □ amount _____________ Pericordial Area □ flat □ bulging □ normodynamic □ hyperdynamic
□ others _______________________________ □ tenderness □ heaves / thrills
Smooth muscle □ tongue moves side to side PMI at _______________
movements □ gag relfex Jugular Veins □ normal □ distension: lying ___degrees, ___cm
Carotid Arteries □ easily palpable □ diminution
Heart Sounds □ faint □ distinct □ S3 □ S4
S1__S2 at base; S1__S2 at apex
□ murmur, grade __ best heard at ____________
Percussion □ cardiac dullness from ___ to ___ ICS

Breast and Axillae

Symmetry □ equal □ unequal
Contour □ masses _________ *R / L+
□ dimpling _________ *R / L+
Skin □ redness □ edema □ lesions _______________
Tenderness □ tender at ___________ □ nontender
Nipple and □ inversion □ flattening / retraction
Areola □ deviation to *R /L+ □ edema

Abdomen
Skin □ dilated veins □ striae □ scar _______________
□ rashes □ lesions _______________________
Umbilicus □ sunken □ bulging □ hernia
Configuration □ flat □ globular □ protuberant □ scaphoid
□ symmetrical □ asymmetrical
Bowel Sounds □ normoactive ____/min □ hyperactive ____/min
□ hypoactive ____/min □ absent
□ dull □ medium □ loud
Bruit □ absent □ present over _____________
Percussion □ tympanitic □ hyperresonant over ___________
Neck
□ dull over ___________ □ fluid wave
Trachea □ midline □ deviation *R /L+
□ shifting dullness
Lymph Nodes □ nonpalpable □ palpable □ enlarged □ tender
 Physical Examination

Palpation □ muscle guarding □ liver: □ tenderness Muscles of the ankles

□ CVA tenderness□ rebound tenderness
□ liver span ____cm □ splenic dullness Reflexes
□ aorta: □ palpable □ well-defined mass Right Left
Psoas Sign Biceps
Obturator Sign Triceps
Pregnant LMP ___wks Brachioradialis
Fundic Height ____cm Patellar
Fetal Position and Lie: [R / L] ______________ Achilles
Fetal Presentation ____________ □ ballottement Plantar
FHR: ______beats/min at _________
Cranial Nerves
Genito-Urinary System (Female) Nerve Name Function Test
Labia □ symmetrical □ asymmetrical I Olfactory Smell
□ lesions ________________ II Optic Visual Acuity
□ pinkish □ discoloration □edema Visual Field
Vaginal Orifice □ discharge: □ purulent □ bloody □ foul smelling III Oculomotor Pupillary Reaction
Others □ swelling □ lumps or nodules at ____________ Ocuar Movements
IV Troculear Eye Movement
Genito-Urinary System (Male) VI Abducens Motor Function
Penis □ discharge: □ purulent □ bloody □ foul smelling V Trigeminal Facial Sensation
□ nodular growth □ lesions ______________ Corneal Reflex
□ tenderness □epispadia□hypospadia Teeth Clenching
Scrotum □ equal □ tenderness □ enlargement *R / L+ VII Facial Facial Movements
□ undescended *R / L+ Taste Sensation
□ nodules / growths / lesions at ____________ VIII Acoustic Hearing – watch tick’s
Others □ hernia □ hydrocele Balance – Romberg’s
IX Glossopharyngeal Tongue Movement
Back and Extremities Taste Senstaion
Peripheral □ symmetrical □ regular □ warm □ absent □ faint X Vagus Gag Reflex
Pulses □ weak □ strong □ bounding Hoarseness
Nails □ pink □ pale □ cyanosis □ inflammation XI Spinal Accessory Sternocleidomastoid
□ clubbing □ blanching Trapezius
Joints □ redness □ warmth □ crepitation XII Hypoglossal Tongue Movement
□ swelling at _____________ and Strength
□ tenderness at _____________
□ full ROM Neurological
□ decreased ROM at _____________
Light touch Sensation □ light tickling or touch sensation
Muscle □ size equal □ atrophy at ______________ □ absence of sensation
□ normal trone□ hypertonic □ flaccid
Pain Sensation □ Distinguishes sharp from dull over
□ fasciculation □ tics □ tremors
□ Reduced/heightened/absent over
□ strength equal: score 0 1 2 3 4 5
Thermal Sensation □ Distinguishes hot from cold over
□ weakness at _____________
□ Reduced/heightened/absent over
□ paralysis at _____________
Kinesthetic Sensation □ Readily determines position of
Fine Motor □ finger-to-nose: □ smooth & accurate □ fail
fingers and toes □ Otherwise
□ heel-to-shin: □ smooth & accurate □ fail
Stereognosis □ recognizes common objects
□ finger movement: □ smooth & accurate □ fail
□ otherwise
Reflexes □ patellar: grade 0 1 2 3 4
Extinction Phenomena □ Both points of stimulus felt at
□ Achilles: grade 0 1 2 3 4
□ Failure to perceive stimulus at
Spine □ midline □ kyphosis □lordosis□ scoliosis
Brudzinski’s Sign □ involuntary lifting of legs
Kernig’s Sign □ at pain when knee is bent and
Peripheral Pulses
Nuchal rigidity extended
Carotid Radial Brachial Femoral Politeal D.pedis P.tibia
□ inability to flex the neck
R
L
Fine motor
Muscloskeletal
Finger to nose test
Right Left Alternating supination of hands
Sternocleidomastoid
Finger-nose-nurse
Trapezius Fingers to fingers
Deltoid
Opposition
Biceps Heal down opposite shin
Ticeps Toe or ball to nurse’s finger
Finger muscles
Grip strength Gross Motor
Hip muscles Walking Gait
Hip abduction Romberg Test
Hip adduction Standing on one foot with eyes close
Hamstrings Heal to toe walking
Quadriceps Toe or heel walking
 Physical Examination

GRADATION OF MURMURS
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
GRADE 4 LOUD WITH PALPABLE THRILL
GRADE 5 VERY LOUD WITH THRILL, HEARD WHEN STETHOSCPOPE IS
PARTLY OFF THE CHESS
GRADE 6 VERY LOUD WITH THRILL, HEARD WHEN STETHOSCPOPE IS
ENTIRELY OFF THE CHESS

GRADATION OF PULSES
0 ABSENT, UNABLE TO PALPATE
1+ DIMINISHED, WEAKER THAN EXPECTED
2+ BRISK, EXPECTED, NORMAL
3+ BOUNDING

GRADATION OF EDEMA
1+ SLIGHTLY PITTING/2MM, DISAPPEARS RAPIDLY
2+ SOMEWHAT DEEPER PIT/4MM, DISAPPEARS IN 10-15 SECONDS
3+ DEEP PIT/6 M MM, MAY LAST > 1 MIN, DEPENDENT
EXTREMITY SWOLLEN
4+ VERY DEEP PIT/8MM, LASTS 2 TO 5 MIN, DEPENDENT
EXTREMITY GROSSLY DISTORTED

GRADATION OF MUSCLES
GRADE 0 NO MUSCULAR CONTRACTION DETECTED
GRADE 1 A BARELY DETECTABLE FLICKER OR TRACE OF CONTRACTION
GRADE 2 ACTIVE MOVEMENT OF THE BODY PART WITH GRAVITY
ELIMINATED
GRADE 3 ACTIVE MOVEMENT AGAINST GRAVITY
GRADE 4 ACTIVE MOVEMENT AGAINST GRAVITY AND SOME RESISTANCE
GRADE 5 ACTIVE MOVEMENT AGAINST FULL RESISTANCE WITHOUT
EVIDENT FATIGUE/ NORMAL MUSCLE STRENGTH

GRADATION OF REFLEXES
GRADE 0 NO MUSCULAR CONTRACTION DETECTED
GRADE 1 MINIMAL ACTIVITY
GRADE 2 NORMAL RESPONSE
GRADE 3 MORE ACTIVE THAN NORMAL
GRADE 4 MAXIMAL ACTIVITY

OTHER NOTES:

SIGNIFICANT PE FINDINGS FROM CHART REVIEW: