Running head: COMPLETE PHYSICAL EXAMINATION
Complete Physical Examination
James Corder
Frontier School of Midwifery and Family Nursing
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COMPLETE PHYSICAL EXAMINATION
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Complete Physical Examination
General Survey:

Vital Signs: Sitting-Bp left 118/64 Bp right114/60, Standing-BP left 112/64 Bp
right 110/62 ,no signs coractation, Temp 98.3,
Pulse 76, 2+ regular rhythms, Respiration 16 unlabored

Appearance: Appears stated age, no signs of acute distress, sexual development
appropriate for stated age, Height and weight appears normal, Sits comfortable in
exam chair, no asymmetry in posture.

Behavior Activity: Maintains eye contact, smiling expression appropriate to
situation, pleasant mood, and cooperative, speech clear with appropriate word
choice, well groomed and clean.
Skin:

Hair: Full medium length blond hair, appears healthy not brittle or dry, scalp
clean, no redness lesions or flaking, no infestation noted.

Nails: Pink round uniform, not brittle, smooth, no clubbing beds 160 degrees, not
thickened.

Skin: pink warm and dry, turgor good, Few scattered senile lentigines back of
hands and forearms, no lesions or rash, pigmentation even. no edema

Mucous membranes: moist, pink, no discoloration of lips or oral cavity.
Head:

Head: Normocephalic, No sinus tenderness, no ateritis, temporomandibular joint
smooth, protraction and retraction no crepitation, facial features symmetric No
COMPLETE PHYSICAL EXAMINATION
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Lympheadnopathy: No palpable nodes Preauricular, Posterior auricular, Occipital,
Submental, Submandibular, and Jugulodigastric.

Eyes: OD20/30, OS20/30, Red reflex present bilaterally, disc flat orange-yellow,
no macular degeneration, no hemorrhage or exudates noted,
normal
confrontational fields, no asymmetry corneal light reflex symmetric, normal
alignment, Pupils PERRLA sclera white, conjunctiva clear no lesions. Brows and
lashes present, six cardinal positions of gaze – parallel tracking both eyes.

Ears: ears are symmetrical, no edema or drainage, discharge, auricles aligned
with eyes, earlobes soft no tenderness, auricles flexible no tenderness in tragus,
Screening: whispered word test 100%, Weber test tone heard equal bilaterally,
Rinne test AC>BC 2:1
Exam: small amount cerumen noted left, cone of light noted ble, tympanic
membrane intact pearl grey, no bulging or retraction, no polyps, no redness or
drainage in canals

Nose: Nose centered and symmetrical, nares patent to sniff ble, nasal septum
centered no discharge or odor, turbinate’s pink and moist no evidence of sinus
pain on palpation.

Throat: oral mucosa pink no cracking or dryness, no lesions, ulceration, # 31
teeth white no caries or malocclusions noted. Uvula midline, tonsils 1+ no redness
or swelling, pharynx pink, smooth and moist, saliva clear tongue freely movable.

Cranial Nerves:
I.
Olfactory: Sensory, intact identifies lemon
COMPLETE PHYSICAL EXAMINATION
II.
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Optic: Sensory, vision, is able to recognize objects up close and at
distance.
III.
Oculomotor: Mixed, motor EOM movement, can perform straight nasal
and up temporal, and down-temporal opening eyelids
Parasympathic, pupils constrict to light.
IV.
Trochlear: Motor, follows down and inward nasal movement of the eye.
V.
Trigeminal: Mixed, motor, sensory able to clinch teeth on command. Can
move jaw forward and laterally against resistance.
VI.
Abducens: Motor, client able to move eyes from side to side, and straight
temporal..
VII.
Facial: Mixed, Motor sensory, no paralysis, taste sweet sour salty, opens
and closes eyes, speaks-labial speech
VIII.
IX.
X.
XI.
Acoustic: Sensory, able to hear, no dizziness or vertigo.
Glossopharyngeal: Mixed, sensory and motor, taste and gag reflex intact.
Vagus: Mixed, sensory and motor, able to talk and swallow.
Spinal: Motor, Able to move trapezius and sternomastoid muscles, client
freely moves shoulder up and down. Able to turn head against resistance.
XII.
Hypoglossal: Motor, moves tongue side to side.
Neck:
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Thyroid:, Thyroid and cricoids cartilage intact, thyroid gland not palpable, no
tenderness, or redness, no nodules or edema, No masses or bruit. Bronchial
sounds ble.
COMPLETE PHYSICAL EXAMINATION
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Symmetry, contour, flexibility: Neck supple, full ROM, chin 45 degrees, side to
side movement 70 degrees, neck and trachea, midline sternocleidomastoid
muscles symmetrical.

Nodes: No lymphadenopathy or palpable nodes superficial cervical, Deep
cervical chain, Posterior cervical, Supraclavicular.
Thorax and Lungs:

Inspection: Scapula symmetrical, No signs kyphosis, costal angle 90 degrees, no
distress, or nasal flaring, no cyanosis, or accessory muscle use. Anterior-Posterior
to lateral diameter 1:2.

Palpation: Chest expansion symmetric ble, ribs stable, skin intact, non tender.
Tactile fremitis present and equal bilaterally.
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Percussion: resonant sounds heard over lung fields, diaphragmatic excursion 4cm
bilaterally, No hyperresonance or dullness noted.

Auscultation: lungs clear to auscultation, vesicular sounds throughout with
bronchovesicular over larger parasternal and between scapulas, no adventitious
sounds rales, rubbing, or rhonchi. No increase voice sounds bronchophony,
egophony or whispered pectoriloquy.
Heart:

Position: Supine HOB 30 degrees,
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Inspection: No edema, diaphoresis, pallor, cyanosis dyspenia or JVD, No visible
pulses noted, heave or lift.
COMPLETE PHYSICAL EXAMINATION
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Palpation: Carotid pulse 2+ ble. No thrill noted, Apical Impulse felt @ left side
lying position Midclavicular 5th intercostals space, Normal Jugular pulsation<
2cm above sterna angle.

Auscultation: PMI rate regular @ 84, S1 + S2 audible, no S3 or S4, clicks, or
splitting noted,
no pulse deficits, no mid-systolic click, gallops or murmurs
sitting leaning forward.
Peripheral vascular:

Pulses: extremities pink, capillary refill < 2 sec. no cyanosis, no edema, hair
growth noted lower legs, pulses equal strength ble, brachial 2+, radial 2+, ulna 2+,
Femoral 2+, Popleteal 2+, Posterior tibial 1 +, Dorsal pedal 2+.
Abdomen:
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Inspection: abdomen flat smooth and symmetrical, small silver striae right and left
lower quadrants,

Auscultation: bowel sounds present all quadrants, no vascular bruits,

Palpitation: light and deep, unable to palpate spleen or kidney no nodules nontender no masses, liver border 1 cm below costal margin smooth no tenderness,
gallbladder not palpable, Aorta pulsation palpable left midline < 2cm wide.
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Percussion: Tympany heard throughout abdomen, area of dullness heard left
lower quadrant descending colon, liver span 8cm with dullness at right costal
margin, Tympanic over spleen, Kidney percussed 12th rib sitting thud felt no
tenderness.
Musculoskeletal:
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Extremities:
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a. Shoulders: symmetrical no atrophy, no redness, edema, no synovial
thickening, no crepitation, able to shrug against resistance, forward flexion
180 degrees, hyperextension 50 degrees, external rotation 90 degrees.
b. Elbows: symmetric ble, no nodules, redness, or tenderness, no synovial
thickening, can flex and extend against resistance, no crepitation,
pronation and supination 90 degrees. ROM flexion 150 degrees- to 0.
c. Wrist and Hands: smooth no redness ,edema, nodules, or tenderness noted,
proximal and distal phalangeal joints no redness or spindal edema, ROM
wrist extension 70, flexion 90 degrees, fingers 30 degrees hyperextension
and 90 degrees flexion, ulnar deviation 55 degrees, radial 20, negative
Phalen’s and Tinel’s test.

Back Joints and muscles:
Spine straight non-tender and symmetrical ble, shoulder, scapula and iliac
crest equal horizontally, vertebral muscles firm no spasms or tenderness
noted. ROM= extension 30 degrees, flexion 90 degrees, rotation 30
degrees, lateral bending 30-35 degrees, negative Lasegue’s test.
Neurological:
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Motor: strong smooth muscle movement no tics, or rigidity, gait smooth rhythmic
arm swing, smooth 16-18 inch step tandem walking straight and balanced smooth
turns, shallow knee bends smooth and effortless, Negative Romberg test, RAM
smooth and rhythmic thumb to finger, finger to nose, finger to finger all smooth
and accurate. Heel to shin test smooth and accurate ble.
COMPLETE PHYSICAL EXAMINATION
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Sensory: Able to distinguish between hot and cold, sharp and dull, tuning fork
vibration felt equally over bony prominences ble light touch symmetric,
kinesthesia- detects upper and lower position changes, stereognosis- accurately
describes objects in hand, graphesthesia-identifies number drawn in hand, no
tactile deficits- able to differentiate between light and heavy touch. Two-point
discrimination intact, range 2-8 mm in fingertips, 40-80 mm upper arms thighs
and back.

Reflexes: No clonus, or hypo-hyperreflexia noted bilaterally, brachioradius 2+,
triceps 2+, biceps 2+, quadriceps 2+, Achilles 2+, Abdominal,2+, upper and lower
planter 2+ Bilaterally, Negative Babinski.
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Mental Status: Awake, alert and oriented times three.
COMPLETE PHYSICAL EXAMINATION
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