@stylebysumiyah
1
GENERAL ORDER OF THE EXAM *
• Inspect → visually observe pt
• Palpate → use hands to feel pt
• Percuss → light striking of body parts to
produce sounds
• Auscultate → listening to body w/stethoscope
o Bell = low-pitch sound
o Diaphragm = high-pitch sound
*All systems except GI
4 CLASSICAL ASSUMPTIONS
• A & O x 4 (person, place, time, situation)
• Vital signs WNL
• Visual acuity assessed via Snellen chart
(CN 2 – Optic)
• Patient is in NAD
PREPARATION
• Knock on entry
• Introduce yourself
“Hi, my name is Sumiyah, and I’m a
nursing student. I will be performing
a physical exam on you today.”
Hand hygiene
o
•
GENERAL SURVEY
• Physical Appearance
o Age, sex, race/ethnicity
• Body Structure
o Tall/short
o Underweight/overweight/average weight
o Proportionality of weight to height
• Mobility
o Ease in ambulation
o Ease in movement of limbs
• Behavior/Mood
o Response to questions
o Grooming/hygiene
o Affect/speech/eye contact
Ex: “Pt is a (#) y/o (gender ident.) of avg. &
proportional height & weight, who moves easily
& responds to questions. They are well groomed
& have appropriate affect to situation.”
SKIN
Inspect
• Entire body → color, lesion, hair distribution
• Finger/Toenails → pitting or clubbing
• Describe lesions noting number, location,
arrangement & type & document later
Palpate (Use the back of the hand)
• Moisture, temperature, texture, turgor
(pinch back of hand), checking for tenting
• Note areas of tenderness or induration
“I will continue to inspect the rest of the body
bilaterally throughout the remainder of my
exam”
HEAD → NCAT
Inspect
• Skull → general size & contour
• Scalp → lesions or inhabitants
• Hair → quantity, texture, distribution, balding
• Face → symmetry (eyebrows, palpebral
fissures in line with helices of ears, nasolabial
folds)
Palpate
• Skull → deformities or tenderness
• Temporal Artery → induration & intensity
(2+ = normal)
• TMJ → pain, popping or crepitus
(pt. open/close mouth)
Neuro Test
• CN 7 (Facial - motor) → pt. smile, frown,
puff cheeks, resist eye opening
• CN 5 (Trigeminal - motor) → pt. clench jaw
– masseter muscle engaged
• CN 5 (Trigeminal - sensory) → light touch x6
(ask pt. close your eyes & say “now” when you
feel it)
“Pt is normocephalic – atraumatic”
NECK
Inspect
• Obvious masses or pulsations
Palpate
• Lymph nodes of head & neck; identify chains
o Preauricular, postauricular, occipital
o Tonsillar, submandibular, submental
o Anterior cervical, posterior cervical &
deep cervical (lean R/L)
o Supraclavicular, infraclavicular
o Non-palpable or <1cm, mobile, & nontender
• Carotids → pulses
• Trachea → deviation
• Thyroid → size, symmetry, tenderness,
consistency, nodules (palpate from behind)
Auscultate
• Carotid & Thyroid for bruit
Neuro Test
• CN 11 – Spinal Accessory (motor) → shrug
shoulders, turn head against resistance
“CN 2 – 12 are intact”
2
EYES → PERRLA & EOMI
Inspect
• External Inspection
o Eyelashes → point out & away
o Conjunctiva/sclerae/cornea → clear &
moist
o Pupil → size & shape
o (3-5mm b/l, round)
•
3 Finger Test
o Visual fields on confrontation
(CN 2 – Optic) (Jazz hands)
▪ Start laterally → Ask pt. stare
straight in front & let me know
when you see my fingers
o 6 cardinal fields of gaze (CN 3, 4, & 6 –
Oculomotor, Trochlear & Abducens)
(Cat Whiskers)
▪ Ask pt. follow my finger & not
move your head
o Accommodation & Convergence
(CN 2 & 3) (Follow Finger)
▪ Ask pt. to follow my finger as I
bring it closer to pt. face & away
•
2 Light Test (Pen light)
o Direct (CN 2) constrict & consensual
(CN 3) light reflexes, consensually
constricts
o Corneal light reflex → strabismus
(shine light & see that the light falls in the
same place in both eyes)
•
1 Ophthalmoscope Exam
(Right Eye to Right Eye)
o Catch red light reflex & move closer into
pt.
o Optic disc → clear, well defined, creamy
yellow
o 4 sets of retinal vessels
o Macula → 2 optic discs away
“Pt is PERRLA & EOMI - Pupils are equal,
round, reactive to light & accommodation ;
Extra ocular movements intact”
EARS
• Assess gross hearing
(CN 8 – Vestibular Cochlear)
o Normal conversation
o Whisper test/finger rub
o Ask pt. to close their eyes & point
to the ear where they hear the
finger rub
o If abnormal, continue to Weber
(midline) & Rinne (AC>BC) test
Inspect
• Auricle → symmetry, lesions, nodules
• Special attention to back & top of ears as it is
a common site for skin cancer
Palpate
• Tragus & mastoid → tenderness
Otoscopic Exam
• Maneuver Auricle
o Adults Pinna → up & back
o Peds Pinna→ down & back
• Inspect canals → cerumen (ear wax), foreign
bodies, inflammation, discharge
• Inspect TM & note presence of the
following/abnormalities
o Not bulging or retracted
o Pearly gray color
o Bony prominences
o Cone of light (R ‘ 5; L ‘ 7)
MOUTH & PHARYNX
3
Inspect
• Lips → swelling, color, lesions (ask pt. to
smile)
• Teeth & gums → dentition, swelling, color,
lesions (ask pt. to open mouth)
• Buccal mucosa → color, moisture, lesions
• Tongue → lesions, moisture, texture
o Pink, moist & well papillated
• Presence of Wharton (underneath tongue) &
Stenson ducts (upper 2nd molar)
• Posterior pharynx → color, exudate, lesions
o Non-red, non-injected
o Grade tonsils (1-4)
• Patency of salivary glands → parotid &
submandibular
Neuro Test
• CN 12 (Hypoglossal) → stick out tongue,
noting deviation
• CN 9 (Glossopharyngeal - motor/sensory) →
press down w/ tongue blade, ask pt. to say
“ah,” noting rise & position of uvula
• CN 10 (Vagus) → gag reflex
NOSE & SINUSES
• Assess nasal patency
o Ask pt. to occlude one nostril by pinching
down & breath in
Inspect
• Nose → midline
• Septum → deviated or perforated
• Nasal mucosa → color, exudate, swelling,
polyps
o Mucosa → moist, pink
o Turbinate’s → beefy red
Palpate
• Frontal & maxillary sinuses → tenderness
4
POSTERIOR LUNGS
Inspect
• RR & rhythm, overall effort (RR 12-20)
• General contour, spine midline
• Rib interspaces, accessory muscles
(are they using them?), no retractions
Palpate
• Respiratory expansion (thumbs rise and fall
equal bilaterally, note symmetric expansion of
hands)
• Tactile fremitus – feeling for vibrations
diminishing (4 spots) “99” (palmar surface)
Percuss
• Diaphragmatic excursion (3-5cm) bilaterally
o Ask pt. to breathes out → percuss from
resonance to dullness
o Ask pt. to breathes in → percuss from
resonance to dullness
o Flat = bone
o Dull = organ
• 7 spots: intercostal spaces (ICS) → resonance
• Percuss right middle lobe (RML)
Auscultate
• Lung fields: same 7 spots
(deep breaths in/out w/ open mouth)
o Assess right middle lobe (RML)
• Normal clear breath sounds are
o BV → superior medial
o V → peripheral lung
• Note adventitious breath sounds: wheezes,
crackles, pleural rubs, stridor
ANTERIOR LUNGS (in front of pt.)
Inspect
• RR & rhythm, overall effort
• General contour
• Rib interspaces, accessory muscles
(are they using them?), no retractions
• Transverse: Anterior-Posterior diameter
→(2:1)
Palpate
• Respiratory expansion (thumbs rise & fall
equal bilaterally, note symmetric expansion of
hands)
• Tactile fremitus – feeling for vibrations
diminishing (3 spots) “99” (palmar surface)
• Fluid = better sound of “99”
Percuss
• 6 spots: ICS → resonance
Auscultate
• Lung fields: same 6 spots
(deep breaths in/out w/ open mouth)
• Normal clear breath sounds (V, BV)
• Note adventitious breath sounds
5
Vitals Check Reminders
• Radial Pulse
o Bilaterally; note differences if any
• Blood Pressure
o Pt. should be at rest in a comfortable,
relaxed position, legs uncrossed
o Continue to fill air bladder 30mmHg
beyond the disappearance of sounds of
turbulent flow to account for the
auscultatory gap
CV NECK
Inspect
• Carotid/jugular pulsations, neck vein
distention (JVD)
Palpate
• Carotid pulse → bilaterally (one at a time)
Auscultate (Bell)
• Carotids → presence/absence of a bruit
• Instruct pt. to hold breath/hold breathe w/ pt.
CV CHEST
Inspect
• Precordium → heaves or lifts
Palpate
• Palmar surface of hand over;
o Auscultatory areas (see pics) → thrills
o Location of PMI
Auscultate
• Note murmurs, rubs or gallops
Diaphragm and Bell (sitting)
• Aortic (2 ICS RSB) →
S2 > S1
• Pulmonic (2 ICS LSB) →
S2 > S1
• Erb’s Point (3 ICS LSB) →
S2 = S1
• Tricuspid (5 ICS LSB) →
S1 > S2
• Mitral (5 ICS MCL) →
S1 > S2
Bell in the left lateral decubitus position
(knees up on side)
• Mitral/Left ventricle (PMI)
Diaphragm while leaning forward
• Aortic & Pulmonic
6
ABDOMEN
*Inspect, Auscultate, Percuss, Palpation*
(4 quadrants, start at RLQ→ clockwise)
Inspect
• Stand on pts RIGHT side
• Patients arms by their sides, (not above their
head) lying down, knees bent → go to
bathroom if necessary
• Visualize skin-note, symmetry, scars,
masses, protuberance, distention, increased
or absent aortic pulsations, general size,
contour, shape
Auscultate
• Auscultate for bowel sounds → 4Q, 530x/min (diaphragm)
• If absent, listen for 5 mins
• Auscultate for abdominal bruits
(aorta/renal/iliac/femoral) (bell)
“Bowel sounds are normal active in
all 4 quadrants”
Percuss
• Percuss all 4Q’s in a z-like pattern
o 2 spots/quad
• Identify areas of tympany & dullness
o Pay special attention to the flanks
for areas of dullness → tympany
to dullness
• Measure the vertical span of the liver
o From lower border:
▪ Tympany →dullness
o From upper border:
▪ Resonance → dullness
o 6-12 cm at MCL, 4-8 cm at MSL
• Percuss for splenomegaly
o L anterior axillary line, at lowest
intercostal space
o Percuss (tympanic) →have pt.
breath in →percuss (tympanic)
• Tympany to tympany
Palpate
• Light palpation (1 hand) in all 4 quadrants
o Notice any guarding, wincing,
rigidity, tenderness
• Deep palpation (2 hands) in all 4 quadrants
o Note underlying
structures/masses
• Palpate lower edge of liver
o Hold from back with one hand and
the other on the edge
o Under R costal margin, ask pt to
breathe in
o Soft, sharp, smooth, non-tender, no
nodules
• Palpate for splenomegaly
o Reach L hand around to
support/press L rib cage up, push R
hand in toward costal margin
o Ask pt. to take a deep breath,
palpate for tip of spleen deep to the
L costal margin
o Normal spleen not palpable (the tip
of the spleen)
• Palpate for kidneys using “capture
maneuver”
o Stand on R, ask pt to inhale - put R
hand above, L hand below to
“capture” kidney
o Ask patient to exhale/hold - slowly
release R hand to feel kidney
▪ Note size, contour,
tenderness
o Palpate L kidney on L side
o Palpate and estimate abdominal
aorta (<3cm)
o CVAT → ask pt. to sit upright
o Tap with hand/fist at CVA margin
bilaterally
o Ask pt. if they feel any pain
7
MUSCULOSKELETAL
Inspect
• Inspect spine for alignment
Palpate
• Palpate spine for tenderness
Range of Motion Test
• Assess for asymmetry, erythema, heat,
swelling, tenderness, masses, bogginess,
crepitus, and limitations in ROM
• DIP, PIP, MCP
• Wrist, elbows, shoulders ACTIVE
o For shoulder: elbow rests at side
• Knee, hips, legs
o Abduction, adduction
▪ Away/towards body
o Internal rotation, external rotation,
circumduction
o Leg: internal, external, flexion
o Ask pt to lie down now
• Ankles
o Inversion, eversion, plantar flexion,
dorsal flexion
• Toes
o Wiggle
o Abduct/adduct
• Neck
o L/R motion
o Circumduction
• Spine (while standing)
o Lean back, lean forward, rotate side
to side
o Place hands between pt for support
Muscle Strength Test
• Assess muscle strength against resistance
for shoulders, elbows, wrists, hand grips,
fingers, hips, knees, ankles
o Hints:
▪ Arms: parallel push/pull;
genie up/down
▪ Hand: spread fingers &
don’t let me close them;
▪
▪
▪
squeeze my fingers as
hard as you can
• Cross fingers
here
Hips: thighs push up
Knees: shins push out,
pull back
Feet: push up, push down
“Muscle strength graded at 5/5 conducted against
resistance”
Muscle Grading
5/5 = Good against resistance
4/5 = Less strength
3/5 = against gravity, not resistance
2/5 = contractions
1/5 = very limited
0/5 = flaccid
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9
NEUROLOGICAL
Mental Status:
o A & O x 4 (person, place, time, situation)
Cranial Nerves:
o “CN 2 – 12 are intact”
Motor:
o “I am assessing for normal muscle bulk and
tone”
• ROM
o “ROM is intact”
• **Muscle strength**
o Perform (listed on previous page)
Sensory:
• Spinothalamic tract
o Perception of light touch
o Cotton ball on diff. dermatomes
▪ 5 different points
o Perception of pain (sharp/dull test)
▪ Show and state what a
sharp and dull touch is
o “The spinothalamic is intact”
• Posterior column tract (BILATERALLY)
o Vibratory sense
▪ Tuning fork on DIP of
thumb and big toe
▪ Hit fork and then stop
▪ Ask pt. to close eyes &
state when vibration stops
o Proprioception
▪ Demo first. Tell me if
thumb or big toe up/down
▪ Demonstrate what it looks
like first
▪ Use hands on the outside
of thumb of DIP
▪ Ask pt. to close eyes &
state up or down
o Graphesthesia
▪ Draw # in each hand – “3”
or “8”
▪ Ask pt. what # was drawn
o “The posterior column is intact”
Deep Tendon Reflexes
• Brachioradialis, biceps, triceps
o Measure 2 inches using hammer
o Hit your thumb & not pt.
• Patellar, achilles, plantar
o Ask pt. to lie down
o Plantar: Use the back of the
hammer to draw an “L” shape
• “I am grading all reflexes at a 2+”
Cerebellar Function
• Coordination and skilled movements
o Rapid alternating movements
(patty cake, peddle bike, finger to
thumb)
o Finger to nose (3 areas each b/l,
noting no tremors)
▪ Switch hands
o Heel to shin
• Romberg test (30 sec standing, eyes closed,
& feet together)
o Support hands
o + exam = swaying
• Pronator drift (30 sec standing, eyes
closed, arms out)
o Palms up
o Over/under compensation (tap
across both arms)
• Evaluate gait and general posture
o Ask pt. to walk 10 steps
10
11
changes to dullness over the liver with a
skin pencil.
5. Measure the distance between upper and
lower border of dullness in cm. Liver span
depends on age, sex, and body type. The
liver span is normally 6-12 cm (mean liver
span is 7 cm for women and 10.5 cm for
men).
6. If the liver span is increased, percuss
laterally and medially. Normal liver span
in the midsternal line is 4-8 cm.
Spleen percussion
•
Liver Span percussion
• Increased liver span on percussion indicates an
enlarged liver, which can underlie a variety of
pathological processes. It is essential to identify
both the lower and the upper borders of the liver
dullness to distinguish between an enlarged liver
(which has an increased span), and a liver
displaced downwards as a result of chronic
obstructive pulmonary disease (in which case the
liver span is normal).
1. Start by locating the right midclavicular
line. Lightly percuss in the right
midclavicular line upwards starting in the
area of tympany below the umbilicus.
Bending down to listen carefully to the
percussion note might be required.
2. Make a mark where the tympany changes
to dullness (lower border) with a skin
pencil.
3. Percuss in the right midclavicular line
downwards starting at the nipple line to
identify an upper border of liver dullness.
4. Mark the point on the abdominal wall
where the resonant sound over the lungs
•
•
•
The spleen is located slightly posterior to
the left midaxillary line and produces an
oval area of dullness between the 9th and
11th ribs. Only a small surface of a normal
spleen is superficial enough to be
detected, and the splenic dullness is often
obscured by gastric or colonic tympany.
However, an enlarged spleen is expanded
towards the midline, anteriorly, and
downward, and might be detected by two
special percussion maneuvers: Traube's
space percussion and/or Castell's
maneuver.
Percussion of Traube's space, anterior
axillary line, and left costal margin.
• Along with the other pathological
conditions medial expansion of
an enlarged spleen can produce
dullness on percussion over
Traube's space.
• With the patient supine and their
left arm slightly abducted,
percuss from the medial to lateral
border of Traube's space.
Dullness on percussion or
reduction of the area of tympany
can result from splenomegaly.
12
Castell's method (checking for a splenic
percussion sign).
• Percuss in the anterior axillary
line in the lower intercostal space.
• Ask the patient to take a deep
breath, and percuss again. A
normal-sized spleen is positioned
above the percussion point even
when it descends during
inspiration, and the percussion
tone is tympanic on both
expiration and inspiration.
If percussion note is dull or becomes dull
on inspiration (positive splenic percussion
sign), splenomegaly is suspected
Capture Maneuver-kidney palpation
•
•
•
•
•
Start with the right side and place one
hand under the patient's right flank and the
other hand at the right costal margin.
Instruct patient to take a deep breath and
at the height of inspiration press the
fingers of both hands together to try to
capture the kidney then have
patient exhale and hold
Slowly release the pressure and feel for
the kidney to slide between your fingersit may not be palpable
Try to capture the left kidney –the left
kidney is less likely to be palpable If the
kidneys are palpable they should be
smooth firm and non-tender
13
Abbreviations & Definitions
A & O = alert and oriented
Apnea = temporary cessation of breathing
Avg. = average
b/l = bilaterally
BV = bronchovesicular lung sounds
CN = cranial nerve
Crackles = rales, foil rubbing together, rattling sound
CVAT = costal vertebral angle tenderness
DIP = distal interphalangeal joint
Dull = soft, muffled sound, organs
Dyspnea = difficulty breathing
EOMI = extra ocular movements intact
Flat = soft, high-pitched sound, bone
GI = gastrointestinal
Heave = heart beating out of chest
Hyperpnea = extremely deep breathing
Hyperresonance = overinflated lung, lower-pitched
Hyperventilation = extremely rapid breathing
Hypoventilation = extremely slow breathing
ICS = intercostal spaces
Ident. = identity
Kussmaul’s = marked increase in depth & rate
LSB = left sternal boarder
MCL = midclavicular line
MSL = midsternal line
mm = millimeters
NAD = no acute distress
NCAT = normocephalic – atraumatic
Orthopnea = body must be upright to breathe
Paradoxical = one lung deflates during inhalation
PERRLA = pupils are equal, round, reactive to light
& accommodation
PIP = proximal interphalangeal joint
PMI = point of maximum impulse
Pt = patient
Q = quadrants
Rales = small clicking, bubbling
Rhonchi = low-pitches snoring sound
Resonance = normal breath sounds
RR = respiratory rate
RSB = right sternal boarder
S1 = “lub” closing of AV tricuspid and mitral valve,
dull & low-pitched
S2 = “dub” closing SA pulmonic and aortic valve
Stridor = high pitch wheezing
Thrills = vibrations like cat purring
TMJ = temporomandibular joint
Tympani = loud, drum-like sound found in air-filled
viscera
V = vesicular lung sounds
w/ = with
Wheeze = high-pitched sound by narrow airway
WNL = within normal limit
y/o = years old
# = Number
& = and
PULSES:
Peripheral pulses should be
compared for rate, rhythm &
quality
0
+1
+2
+3
+4
Absent
Weak & thready
Normal
Full
Bounding
EDEMA:
Assess by placing thumb over
dorsum of the foot or tibia for
5 seconds
0
+1
+2
No edema
Barely discernible depression
A deeper depression (<5mm)
w/ normal foot & leg contours
Deep depression (5-10mm) w/
foot & leg swelling
Deeper depression (>1cm) w/
sever foot & leg swelling
+3
+4