CHERRAAN’S COLLEGE OF NURSING, COIMBATORE

PHYSICAL EXAMINATION FORMAT

Name :

Age :

Sex :

Diagnosis :

Ward :

GENERAL EXAMINATION

Consciousness : conscious / Semi-conscious / Unconscious

Orientation : Oriented to time, place and person

Nourishment : Well nourished / Moderately nourished

Body Built : Thin / Moderate / Obese

Activity : Active / dull

Look : Pleasant / happy / alert / sad / depressed / fearful / anxious / tired / etc.,

Speech : Clear / Sluring / Stammering / Maintains eye contact

Anthropometric measurement:

Height :

Weight :

BMI : weight in kg/ height in m2

Vital Signs :

Temperature : .................. C/F

Pulse : ..................... beats / min

Respiration : ............... breaths / min

Blood Pressure : ............. mm of hg

A. INTEGUMENTARY SYSTEM

SKIN

Colour : Fair / brown / dark in complexion

Skin turgor : Normal / decreased

Discolouration : absent / yellowish /cyanosis /vitiligo / Increased pigmentation / pallor / etc.,

Lesions / Masses : absent / macule / papule / nodule / vesicle / bullae / plague / cyst / Erosion /
abrasion / ulcer / fissure / crust / scar / keloid / erythema/ pustule/ wheal /
etc.,

Subjective Symptoms : No complaints / pruitis/ pain/ feeling of cold/ warmth / tingling / numbness /
etc.,

NAIL

On observation : Intact / onchylosis/ peeling or cracked

Nail beds : Pink / cyanosed / pale / etc.,

Nail plate : Flat / clubbing / whitening / etc.,

Capillary refill : .......... seconds

Cyanosis : absent / if present ( specify )

HAIR

Colour : black / brown / red / grey / etc.,

Texture : Normal / dry

Grooming : Not groomed / well groomed

Distribution : Normal / Scanty / bald / alopecia / etc.,

B. HEAD

Shape : Normal cephalic / micro / macro / hydro cephalic / etc.,

Scalp : Clean / pediculosis / presense of drandruff / etc.,

Face : Puffiness / moon face / bells palsy / etc.,

C. EYES

Eye brows : Symmetrical / Asymmetrically distributed / scanty / etc.,

Eye lashes : Equally distributed

Pupillary reflex : PERRLA (Pupils Equal Round Reactive to Light and Accommodation) /
unequal reaction to light

Pupil shape : round / oval / yellowish in colour/ etc.,

Conjunctiva : Normal / pale / yellowish / red / flushed / etc.,

Vision : Normal / if abnormal ( specify including use of spectacles)

Corneal reflex : present / absent

Subjective symptoms : No complaints / pain / itching / increased or decreased production of tears

D. EARS

Pinna : Normally placed / anotia / microtia / macrotia / etc.,

Cerumen : canal is clear / blocked

Ottorhoea : absent / purulent / serous /blood / sanguinous / etc.,

Hearing : Normal / decreased / hearing loss / etc.,

Subjective symptoms : No complaints / otalgia / tinnitus / vertigo / etc.,

E. NOSE

Nasal septum : midline / deviated

Nasal pathway : patent / obstructed / nasal polyp / etc.,

Smell : Normal / absent

Nasal discharge : absent / watery / purulent / mucoid / epistaxis / etc.,

Frontal maxillary sinuses : painful / tender / absent / etc.,

F. MOUTH AND PHARYNX

Lips : Colour pink / pale / dark / etc.,

Symmetrical / asymmetrical

Gums : pink in colour / bleeding / swollen / spongy / etc.,

Teeth : colour ( white / yellowish / stains / etc) Dental caries / no of teeth

Mucus membrance : pinkin colour / moist / dry / lesions / (specify) etc.,

Breath odour : Halitosis ( present / absent )

Pharynx : gag reflex ( present / absent )

Voice : Clear / harsh / aphonia / dysphonia / etc.,

Subjective symptoms : No complaints / toothache / dysphagia / odynophagia / throat pain / etc.,

G. NECK

Range of motion : possible / painful / absent / etc., ( check all the movement of flexion,
extension, hyper extension, rotation, lateral flexion)

Lymph node : not enlarged / enlarged / painful / size of the lymphnode / etc.,

Trachea : midline / deviation / etc.,

Thyroid gland : not enlarged / enlarged / removed

Jugular vein : distended / not distended

H. CARDIORESPIRATORY SYSTEM

Thorax : symmetrical / assymetrical / pectus carinatum / barrel chest / etc.,

Thorax expansion : Normal / symmetrical / delayed / shallow / etc.,

Heart sounds : S1, S2 / murmur / gallop sound / etc.,

Breath sounds : normal / wheeze / friction / rhonchi / crackles / stridor / etc.,

Apical pulse : .......... beats / min

Cough : absent / if present ( dry / whooping / productive ) / etc.,

Sputum : absent / if present ( bad odour, consistency, frothy / mucoid / rusty/ sticky /
purulent ) etc., Colour – green / yellow / blood stained / etc ., )

Subjective symptoms : No complaints / diaphoresis/ breathless / giddiness / palpitation / chest pain /

I. BREAST & AXILLA

Symmetry : symmetrical / asymmetrical

Nipple : colour ........ / retracted / inverted etc.,

Discharge : absent/ milky / yellowish / purulent / etc.,

Lesions / masses : absent / ulceration/ nodes / swelling / moving / painful / tender / etc., /
lymphnode sizes.

Axillary nodes : not palpable / palpable / moving / painful etc.,

Hair distribution : Well distributed / scanty / etc.,

On Inspection : Flat / linea nigra / distention / scar / hernia / peristaltic movement / umbilicus
– clean / everted / etc.,

On Auscultation : bowel sounds / murmurs

On percussion : fluid / masses / air / etc., (detected / not detected)

On palpation : soft / tender .... liver / spleen / masses / etc., (palpable / non palpable)

Subjective symptoms : no complaints / nausea / vomiting / heart burn / abdominal cramps /

K. MUSCULOSKELETAL

Postural carves : Normal / kyphosis / lordosis / scoliosis / etc.,

Muscle tone : normal / hypertonia / hypotonia / flaccid / spasticity / rigidity / etc.,

Muscle strength : weaker than normal / normal / active / hyperactive / etc.,

L.UPPER EXTREMITIES

Symmetry : Symmetrical / asymmetrical

Range of motion : possible / if not possible (specify) (check all the movement of Flexion,
Extension, Rotation, adduction, abduction, Pronation, Supination)

Peripheral pulse : radial pulse ( normal rate, rhythm) , if abnormal ........

Reflexes : biceps , triceps (normal)( if abnormal ) ...........

Swelling : absent / if present ( specify area ).........

Cyanosis : absent / if present ( specify area ) ........

Joints : stiffness / swelling / tenderness / crepitus / etc., / absent

Deformity : absent / if present ( specify )

M. LOWER EXTREMITIES

Symmetry : Symmetrical / asymmetrical

Toe nails : blanch to test capillary refill ........ seconds

Range of motion : possible / if not possible ( specify ....... )( check all the movement of Flexion,
Extension, Adduction, Abduction, Plantar flexion, Dorsiflexion, Inversion, Eversion)
Peripheral pulses : dorsalis pedis , posterior tibial artery etc., ( normal rate, rhythm volume) ( if
abnormal ) ......

Reflexes : Patellar, Achilles, Plantar (normal) (if abnormal) .........

Oedema / Swelling : absent / if present ( specify area ) ........

Cyanosis : absent / if present ( specify ) ........

Joints : stiffness / swelling / tenderness / crepitus / etc., / absent

Deformity : talipes euino varus / talipes equino valgum / bow legs / etc., / absent

Gait : normal / limps / steppage / scissoring / dystonia / ataxia / etc.,

Subjective symptoms : no complaints / pain while walking or doing any activities / muscle cramps /
myalgia / problems with flexion , extension , abduction , adduction , external
and internal rotation etc.,

N. GENITOURINARY SYSTEM

GENITALIA ( FEMALE )

Labia majora : dark pink and moist / oedema / lesions / laceration

Labia minora : soft / atrophy / adhesions / ulcers / dry

Urethral orifice : Intact / discharge / polyps / fistulas

Vaginal orifice : Normal / cystocele / rectocele / bulging / discharge / tenderness / lesions

GENITALIA ( MALE )

Penis : smooth and pink / discharge / lesions, oedema

Scrotum : symmetry / lumps / nodules

Inguinal ring : tender / bulging

RECTUM AND ANUS

Inspection : no protrusion / lesions / external haemorrhoids / ulcers / rashes

Digital palpation : intact / mass / bleeding / patent lesion