PHYSICAL EXAMINATION

General Appearance
Development
Nourishment
Body habitus
Deformities
Attention to grooming
Comprehension and language skills (also noted in history)
Vital

signs
Temperature, height and weight (often done by nurse)
Respiration
Pulse regular, irregular or irregularly irregular (as in atrial fibrillation A fib)
Blood pressure (BP) both arms - check for orthostatic hypotension by taking blood
pressure with patient standing - (if elevated then obtain BP sitting, lying, standing and in
legs to rule out coarctation of the aorta)

Skin
Inspection describe
configuration and pattern of any lesions
Hair distribution and texture
Hyperthyroidism thin hair
Hypothyroidism loss of outer 1/3 of eyebrows
Nails color (pale, cyanotic), shape (clubbing angle between cuticle and nail > 180
degrees)
Palms color (erythematosus or redness), pigmented nodules (syphilis)
Soles flat feet (pes planus)
Lymph Nodes
Palpate for size, consistency, tenderness and matting (soft and tender infection, hard
cancer, lymphoma)
Occipital, postauricular, preauricular
Submaxillary - submandibular, submental, anterior and posterior cervical
Supra- and infraclavicular
Axillary, epitrochlear, inguinal

HEAD, EYES, EARS, NOSE AND THROAT (HEENT)

Head
Shape, scars and size

Eyes

External eye structures

Visual acuity use pocket-sized visual cards, color chart
Extraocular movements (EOM) and convergence
Pupillary light reflex (direct and consensual) and accomodation
Visual fields by confrontation
Ophthalmoscopy

Ears

External canals
Gross hearing (rub fingers together next to ears)
Weber test place tuning fork in middle of forehead
Rinne test place tuning fork behind ear on mastoid process
Otoscopy look at tympanic membrane

Nose
External nares (polyps, condition of mucosa), turbinates, septum (deviation from the
center from fracture)
Sinuses (tap them for tenderness, particularly over the maxillary sinus, transilluminate
if abnormal)

Throat

Lips (pale anemia, cold sore viral infection)

Buccal mucosa (pale anemia)
Gingiva (gums) bleeding, hypertrophy (thick and swollen due to taking Dilantin)
Teeth presence, state of repair, dentures
Hard and soft palates clefts, masses
Tonsils (red, swollen with exudates tonsillitis)
Floor of mouth (ranula stone in duct of submaxillary gland)
Gag reflex

Neck
Scars, masses
Anterior and posterior cervical nodes
Carotid artery pulse (also, auscult for a bruit first)
Observe jugular vein for distention (increased jugular venous pressure JVP)
Check for tracheal position in midline and for free movement of trachea
Palpate thyroid gland for enlargement and nodules
Chest
Anterior
Inspect sternum (marked central depression of sternum pectus excavatum, pigeon
breast pectus carinatum)
Inspect ribs (point tenderness fracture of rib)
Inspect for scars and for symmetrical movement of chest wall with breathing
Palpate for symmetrical movement of chest wall on breathing and for tactile fremitus
Percussion for resonance, dullness, flatness, tympany
Auscultation for breath sounds
Posterior
Inspect for scars, contour, symmetrical motion on breathing, shape and appearance
(kyphosis, scoliosis, kyphoscoliosis)
Palpate for symmetrical motion on breathing and for tactile fremitus
Percussion for resonance, dullness, flatness, tympany and for movement of
diaphragm on both sides
Auscultation breath sounds, rales (crepitations), egophony, bronchophony,
whispered pectoriloquy and rubs
Back
Inspect and palpate
Scars and masses
Costovertebral angle (CVA) tenderness (kidney infection), vertebral tenderness
Presacral and sacral edema
Sacroiliac joint tenderness
Breasts
Inspect and palpate
Dimpling of skin (peau dorange cancer)
Tenderness infection
All quadrants and tail process of Spence
Axillary nodes
Nipple discharge (galactorrhea, blood and pus)
Areolae
Chest wall pain very tender costchondral junctions (Tsetses Syndrome)

Heart
Sitting and lying down (examine all 4 areas mitral, tricuspid, pulmonary, and aortic)
Inspect scars (midsternal scar CABG), pulsations
Palpate Point of maximal impulse (PMI), heaves, thrills, lifts
Auscult - heart sounds, rubs, gallops (S3 and S4) and murmurs
(a) Murmurs
1. Aortic insufficiency (AI) a blowing diastolic murmur off the second
sound at Erbs point (third left intercostal space adjacent to the
sternum), in full expiration, with patient leaning forward, with the
diaphragm of the stethoscope
2. Mitral stenosis (MI) a rumbling diastolic murmur heard with an
opening snap, after exercise, in mitral area, with patient in the left
lateral decubitus position, with the bell of the stethoscope, pressed
very lightly on the skin
Abdomen
Lying flat
Inspect scars, masses, contour, venous pattern
Auscult bowel sounds, bruits
Percussion all four quadrants if pain elicited in any quadrant be gentle on
palpation so as not to have the patient suffer unnecessary pain
Palpate and percussion
(a) Superficial and deep palpation (all 4 quadrants)
(b) Liver and Spleen for consistency and size
(c) Hepatojugular reflex
(d) Shifting dullness
(e) Fluid wave
(f) Masses and herniae include inguinal area
Rectal
Pelvic
Peripheral vascular
Palpate
Carotid pulse also auscult for a bruit first
Radial pulse
Femoral pulse also auscult for bruit
Popliteal pulse
Dorsalis pedis (DP) pulse
Posterior tibial (PT) pulse

Musculoskeletal
Inspect and palpate
Bones, joints and spine
CVA tenderness
Sacroiliac tenderness
Sacral edema
Decubitus ulcers
Muscle atrophy, muscle strength
Tenderness, warmth, swelling and redness of joints, as well as for stability and also
for whether a joint effusion is present
Range of motion (ROM) of joints (perform only if there is a joint problem)
Shoulders elbows wrists fingers
Chest spine (thoracic and lumbar)
Hips knees ankles
Neurologic
Mental status
Level of consciousness
Orientation to time (date), place (where are you?), and person (your name)
Memory - remember 3 words (recent memory), well-known past event (remote
memory)
Insight and judgment reaction to a simple problem
Affect emotional response to an event
Intellectual ability series of 7s (100 7)
Speech, language and comprehension
(a) Aphasia acquired disturbance of language
1. Motor expressive
2. Sensory receptive
(b) Dysarthria disturbance of speech due to problems with articulation of
sounds
Folstein minimental status examination (MMSE) used in geriatric patients
Cranial nerves
I not tested
II visual acuity, visual fields by confrontation (already done under Eyes)
III, IV and VI extraocular movements (EOM), light reflex (direct and consensual),
nystagmus (already done under Eyes)
V sensory and motor of face
(a) Sensory test ophthalmic, maxillary and mandibular divisions
(b) Motor ask patient to bite down hard feel contraction of masseter muscles
VII smile, ask patient to close eyes tightly and dont let you open them, wrinkle
forehead (bilaterally innervated)
VIII hearing, Weber and Rinne tests (already done under Ears)
(1) IX X gag reflex (already done under Throat)

(2) XI shrug shoulders palpate both trapesii muscles and feel contraction, push
chin against examiners fingers of one hand and examiner feels contraction of
sternocleidomastoid muscles with his other hand
XII stick out tongue it should be in midline; if to either side, it points to the side
of the lesion (already done under Throat)
Motor system
Test muscle strength and resistance to passive motion (part of Musculoskeletal
Examination, but fits in here much better)
Reflexes biceps, triceps, brachioradialis, knee jerk (KJ), ankle jerk (AJ)
Babinski reflex
Inspect for
(a) Tremor - involuntary shaking
(b) Fasciculations - irregular, involuntary muscle twitching
(c) Spasticity involuntary increased muscle tone with progressive stretching of
muscle
(d) Rigidity involuntary increased muscle tone throughout range of motion of
muscle
(e) Atrophy - loss of muscle mass
(f) Flaccidity floppiness of muscle
(g) Chorea involuntary twisting and writhing motion
(h) Myoclonus involuntary shock-like motion of muscles with extreme twisting
of joints
(i) Dystonia involuntary, persistent, fixed contraction of muscle
Sensory system
Pain and temperature (use sharp side of pin)
Light touch (use dull side of pin)
(NB pain and light touch are performed together on hands and lower forearm as
well as on feet and lower leg)
Two-point discrimination
Position sense and vibration (testing posterior or dorsal column) hold lateral aspects
of both great toes and both thumbs and move up and down ask patient to close eyes
and identify movement as up or down
Romberg test stand with feet together, arms stretched forward, eyes open and have
patient close eyes (be careful to be ready to catch patient if patient begins to fall) if
patient losses balance or sways with eyes open, cerebellar disease is probably present;
if this occurs with eyes closed , but not when eyes are open, then position sense is
impaired
Cerebellum
Finger to nose test - eyes open (if eyes closed, testing position sense)
Heel to knee (shin) eyes open (if eyes closed, testing position sense)
Alternating movements
Gait
Posture
Walking normally, on toes, on heels and in tandem