PHYSICAL EXAMINATION GUIDELINE I.

General Information Name of Client: __________________________________________________________ Age: ________ Sex: ________ Unit/Ward: ______________ Bed No.: _________ Examiner: _______________________________________________ Home Addres: ____________________________________________________________________________________ II. Vital Signs and Anthropometric Measurements T: ___________________ oral axillary rectal tympanic BP: __________________ sitting lying standing PR: _______________/min RHYTHM: regular irregular VOLUME: absent thready/weak bounding normal HR: _______________/min regular irregular RR: _______________/min DEPTH: normal deep shallow RHYTHM: regular irregular QUALITY: effortless labored use of acce.muscles WEIGHT: __________kg HEIGHT: __________cm BMI: ______________kg/m2 MUAC: ___________ cm WAIST CIRC: _______cm HIP CIRC: _________cm WAIST-HIP RATIO: _____________ IV. Integument General Color: normal pallor cyanosis jaundice erythema vitiligo Texture: smooth rough others: _____________________ Temperature: warm cool others: ___________________ Turgor: good fair poor Moisture: normal dry wet/clammy oily Lesions: PRIMARY: ecchymosis macule patch papule plaque nodule tumor vesicle bulla pustule cyst wheal SECONDARY: atrophy erosion lichenification scales crust ulcer fissure scar keloid excoriation Edema: pitting non-pitting (GRADING: ____________) VI. Head Configuration: normocephalic smooth contour others: ______________________________________ nodules masses depressions Fontanelles: closed open sunken bulging Facial Features: symmetric slightly symmetric asymmetric exophthalmos moon-faced myxedema Facial movements: symmetric asymmetric involuntary facial movements III. General Survey Build: endomorph mesomorph ectomorph Posture and Gait: relaxed/erect coordinated uncoordinated staggering shuffling stumbling unable to walk alone walks with assistive devices Hygiene: clean/neat unkempt halitosis ( ammoniaodor acetone-odor foul-odor) bromhidrosis Nutrition: well-nourished obese cachexic General Appearance: relaxed signs of distress ( pain, cardio-respiratory anxiety) Emotional State: calm worried restless tense others: ______________________________ Development: well fairly poorly looks accdg to age Looks younger older Level of Consciousness: conscious lethargic obtunded stuporous comatose Coherence: coherent incoherent Orientation: oriented to disoriented to ( time person place) V. Nails Color: pink pallor cyanosis Nail Plate: convex spoon-shaped/koilonychia clubbing Capillary Refill: ______ seconds normal delayed Texture: smooth thick thin beaus lines Inflammation: negative positive (characteristics:____________________________________) Hygiene: clean dirty VII. Neck Trachea: midline deviated to ( right left) Lymph Nodes: nonpalpable palpable enlarged tender Thyroid: nonpalpable enlarged Range of Motion: normal rigid Carotid Pulse: ____________/min symmetric asymmetric RHYTHM: regular irregular VOLUME: absent thready/weak bounding normal NVE: ____________ Masses: present absent Tonic Neck Reflex: present absent

USE TO LOCATE PAIN (red), LESIONS (blue), EDEMA (green)

USE TO GAUGE PAIN

<17 17 18.5 18.5 24.9 25 29.9 >30

BMI Interpretation extremely underweight underweight normal overweight obese (>40 extremely obese)

EDEMA GRADING 1+ = 2mm deep 2+ = 4mm deep 3+ = 6mm deep 4+ = 8mm deep

onchitioss VIII. Eyes Lids: symmetrical asymmetrical edema/swelling (R L) ptosis (R L) Periorbital Region: edema sunken discoloration Eyelashes: equally distributed curled outward turned inward Eyebrows: evenly distributed loss of hair symmetrical asymmetrical skin intact scaling flaking equal movement unequal movement Conjunctiva: pinkish pale red extremely pale extremely red lesion discharge Sclera: anicteric subicteric icteric hemorrhages Lacrimal sac and NL duct: non-tender tender Cornea: transparent shiny smooth arcus senilis (+) sensitivity (-) sensitivity Iris: transparent dicoloration opacity cloudiness Pupils: R:_____mm L:_____mm equal unequal Reaction to Light: R brisk sluggish fixed L brisk sluggish fixed Reaction to Accomodation: equal unequal Peripheral Vision: intact smaller than normal half-vision Extraocular Muscle Test: intact non-intact nystagmus Visual Acuity: grossly normal R:____/____ L:____/____ wears eyeglasses/contact lenses (grade: R:___ L:___) XI. Mouth Lips: pinkish pallor cyanosis dry/crack lesions Mucosa: pinkish pallor cyanosis moist dry lesions Tongue: midline deviated to (R L) atrophy fasciculation lesions Teeth: complete incomplete braces retainers Caries (red), Missing (green), Dentures (blue) Gums: pinkish pale bleeding tender nontender Speech: intact slurred aphasic others: _____________ Gag Reflex: present absent Rooting Reflex: present absent Sucking Reflex: present absent Extrusion Reflex: present absent XII. Chest and Lungs Inspiration:Expiration ratio: ____ : ____ Shape: APL ratio: ____ : ____ barrel funnel pigeon Chest Expansion: symmetrical decreased/lag (R L) Tactile Fremitus: symmetrical decreased or increased @ (R L) lung field Percussion: resonant dull tympanitic hyrresonant Breath Sounds: vesicular over ____________

IX. Ears Auricles: symmetrical asymmetrical aligned with outer canthus of the eye low-set ears Color: same as facial skin pallor cyanosis Texture/Elasticity/Tenderness: mobile firm non-tender tender pinna recoils after folded Gross Abnormalities: _________________________________ External Canal/Middle Ear: impacted cerumen discharge ( foul smelling serous purulent mucoid) Gross Hearing: symmetrical deafness (R L) with hearing devices: ___________________________ Rinnes Test: R ______ L ______ Webers Test: lateralization (R L) Startle reflex: present absent X. Nose Nasolabial Fold: symmetrical shallow (R L) Septum: midline deviated (R L) perforated Mucosa: pinkish pallor cyanosis redness discharge ( bloody serous purulent mucoid) Patency: both patent obtructed (R L) Masses/Lesions Sinuses: tender non-tender Gross Smelling: symmetrical olfactory deficiency (R L) bronchovesicular over ____________ bronchial over _____________ Adventitious Breath Sound: absent fine crackles coarse crackles wheezes rhonchi stridor friction rub Sound Vesicular Bronchovesicular Bronchial Fine Crackles* Character Insp. > Exp. Insp. = Exp. Exp. > Insp. Soft, highpitched (510msec) Coarse Crackles* Louder, lower in pitch (2030msec) Wheezes High-pitched; have hissing or shrill quality Rhonchi Low-pitched; have a snoring quality * crackles is sometimes called rales Indication Normal Normal Normal Pneumonia, fibrosis, early CHF, bronchitis, bronchiectasis Narrowed airways as in asthma, COPD, bronchitis Secretions in large airways

Primary Skin Lesions: Macule: flat, 1mm to 1cm Patch: flat, >1 cm Papule: circumscribed, elevated, <1cm Plaque: elevated, >1cm Nodule: elevated, deeper than papule, 0.5 2cm Tumor: elevated, deeper, may be irregular in shape, >2cm Vesicle: circumscribed, with serous fluid, <0.5cm Bulla: circumscribed, with serous fluid, >0.5cm Pustule: vesicle o bulla filled with pus Cyst: >1cm, fluid-filled, deeper than vesicle and bulla Wheal: reddened, irregular in shape Secondary Skin Lesions: Atrophy: dry, paperlike, wrinkled skin surface Erosion: moist, shallow depression, epidermis only Lichenification: rough, thickened, hardened area Scales: shedding flakes of greasy, keratinized tissue Crust: dry blood, serum, or pus left on the surface Ulcer: deep, irregularly-shaped, extending to dermis or subQ Fissure: linear crack with sharp edges Scar: flat, irregular area of connective tissue after wound healing Keloid: elevated, irregular, darkened area of excess scar tissue Excoriation: linear erosion

USE TO LOCATE CARIES (red), MISSING TEETH (green), DENTURES (blue)

onchitioss XIII. Heart Precordial Area: flat bulging normodynamic hyperdynamic tenderness PMI at ____________________________________ pulsation displaced ( laterally lower) heave thrill Aortic area at _______________________________________ pulsation heave thrill Pulmonic area at _____________________________________ pulsation heave thrill Tricuspid area at _____________________________________ pulsation heave thrill Apical area at _______________________________________ pulsation heave thrill Heart Sounds: distinct faint S1 _____ S2 at base S1 _____ S2 at apex Extra heart sounds: S3 S4 Murmurs: absent present (GRADE: _________) Best heard at ____________________________________ Jugular Vein: not visible distended Jugular Venous Pressure*: ____cm elevated not elevated XV. Abdomen Appearance: uniform color striae lesions purple striae tense, glistening skin (for ascites) dilated veins Configuration/Contour: flat globular protuberant scaphoid symmetrical asymmetrical Abdominal Movement: symmetrical asymmetrical peristalsis aortic pulsations Umbilicus: sunken bulging hernia Bowel Sounds: ________/min normoactive hyperactive hypoactive absent Arterial Bruit: absent present ( aortic iliac renal artery) Friction Rub: absent present Percussion: Tympanitic at _____________________________ Dull at ___________________________________ Fluid Wave: absent present Shifting Dullness: absent present Liver: non-palpable enlarged smooth border nodular hard tender non-tender Spleen: non-palpable enlarged tender non-tender Bladder: non-palpable distended Others: muscle guarding direct tenderness rebound tenderness masses: _____________________________ CVA: tender non-tender

XIV. Breast and Axillae Size: symmetrical asymmetrical Appearance: same as color of abdomen or back discoloration striae dimpling/retraction hypervascularization swelling edema Areola: round oval symmetrical asymmetrical Nipples: round everted inverted symmetrical size asymmetreical size discharge: ___________________ Lymph Nodes: palpable non-palpable Breast tissue: non-tender tender masses nodules discharge: ____________________________________ XVI. Ano-Genital FEMALE: Pubic Hair: kinky inverse triangle scant extended to abdomen parasites lesions Labia: symmetrical asymmetrical pinkish discoloration Orifice: same color as surrounding tissue discoloration inflammation swelling discharge lesions Clitoris: _______cm MALE: Pubic Hair: triangular distribution extending to abdomen scant absent others: ________________________ Penis: intact skin slightly wrinkled wrinkled smegma swelling inflammation nodules lesions tenderness immobility smooth/semifirm Meatus: pinkish discoloration discharge:______________ Scrotum: symmetrical asymmetrical marked asymmetry discoloration tightening of skin darker in color enlarged nodules lesions non-tender tender BOTH: Lymph Nodes: non-palpable swelling non-tender tender Femoral Hernia: absent present Inguinal Hernia: absent present Anus: intact skin lesions tender non-tender RectalWall: smooth non-tender tender nodular lesions XVII. Back and Extremities Spine: straight curved kyphosis scoliosis lordosis Joints: non-tender tender redness warm swelling crepitation nodules ROM: move smoothly full decresed at _______________ Muscles: equal in size unequal in size atrophy contractures tremors firm/tonic atonic foot drop Movement: smooth coordinated flaccid spastic Stength: equal unequal (GRADE: __________________)

Grading Muscle Strength: 0 0% of normal strength; complete paralysis 1 10% of normal strength; no movement, contraction of muscle is palpable and visible 2 25% of normal strength; full muscle movement against gravity, with support 3 50% of normal strength; normal movement against gravity 4 75% of normal strength; normal full movement against gravity and against minimal resistance 5 100% of normal strength; normal full movement against gravity and against full resistance

Grading Murmur: 1 Very faint; heard during valsalva maneuver 2 Quiet 3 Moderately loud 4 Loud with palpable thrill 5 Very loud with thrill; with stethoscope 6 Very loud with thrill; without stethoscope USE TO LOCATE ABDOMINAL LESIONS (scars, rashes, etc.)