Mindanao State University – Iligan Institute of Technology

COLLEGE OF HEALTH SCIENCES

PHYSICAL EXAMINATION AND REVIEW OF BODY SYSTEMS

Date: ______________

Vital Signs
Temperature : _______________________ Weight : ______________
Pulse rate : _______________________ Height : ______________
Respiratory rate : _______________________ Body Mass Index : ______________
Blood pressure : _______________________ SpO2 : ______________
Pain : _______________________

*Data can be written in bullet form, use red font for abnormal findings. (narrative)

1. General (Received)
▪ Physical development and body build
▪ Gender and sexual development
▪ Apparent age as compared to reported age
▪ Skin condition and color
▪ Dress and hygiene
▪ Posture and gait
▪ Level of consciousness
▪ Behaviors, body movements, and affect
▪ Facial expression
▪ Speech

2. Integumentary System
▪ Skin – general skin coloration, odors, color
variations, skin integrity, lesions, texture,
thickness, moisture, temperature, mobility and
turgor, edema
▪ Scalp and Hair – general color and condition,
cleanliness, dryness or oiliness, parasites,
lesions, amount and distribution of scalp,
body, axillae, and pubic hair
▪ Nails – nail grooming and cleanliness, nail
color and markings, shape, texture, capillary
refill in nail beds

_______________________ / _________ | 1
 Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES

3. Head and Face – size, shape, and

configuration, involuntary movement, palpate the
temporal artery, palpate the temporomandibular
joint (TMJ)
Neck – position, symmetry, and lumps or
masses, movement of the neck structures, flex
the neck, range of motion, palpate the trachea,
palpate the thyroid gland, palpate the lymph
nodes

4. Eyes
▪ Test distant visual acuity
▪ Test near visual acuity
▪ Test visual fields for gross peripheral vision
(confrontation test)
▪ Perform corneal light reflex test
▪ Perform cover test
▪ Perform the position test
▪ Inspect the eyelids and eyelashes
▪ Observe for redness, swelling, discharge, or
lesions
▪ Observe the position and alignment of the
eyeball in the eye socket
▪ Inspect the bulbar conjunctiva and sclera
▪ Inspect the palpebral conjunctiva
▪ Inspect and palpate the lacrimal apparatus
▪ Inspect the cornea and lens
▪ Inspect the iris and pupil
▪ Test pupillary reaction to light and
accommodation
▪
5. Ears
▪ Inspect the auricle, tragus, and lobule
▪ Palpate the auricle and mastoid process
▪ Perform the whisper test
▪ Perform the Weber’s test if the client reports
diminished or lost hearing in one ear
▪ Perform the Rinne test
▪ Perform the Romberg test

6. Mouth and Throat – lips, teeth and gums,

tongue, ventral surface of the tongue, Wharton’s
ducts, side of the tongue, strength of the tongue,
anterior tongue’s ability to taste, hard and soft

_______________________ / _________ | 2
 Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES
palates and uvula, tonsils, posterior pharyngeal
wall
Nose – nasal color, shape, consisteny,
tenderness, patency of air flow through the
nostrils
Sinuses – palpate, percuss the sinuses,
transilluminate the sinuses

7. Thorax and Lungs

▪ Nasal flaring and pursed lip breathing
▪ Color of face, lips, and chest
▪ Color and shape of nails
▪ Inspect configuration
▪ Observe use of accessory muscles
▪ Palpate for tenderness and sensation
▪ Palpate for crepitus
▪ Palpate for fremitus
▪ Chest expansion
▪ Auscultate for breath sounds
▪ Auscultate for adventitious breath sounds
▪ Auscultate voice sounds
▪ Observe quality and pattern of respiration
▪ Palpate for any surface masses or lesions
▪ Percuss for tone

8. Breasts and Lymphatic System

▪ Color and texture
▪ Superficial venous pattern
▪ Areolas
▪ Nipples
▪ Retraction and dimpling
▪ Palpate texture and elasticity
▪ Palpate for tenderness and temperature
▪ Palpate for masses
▪ Palpate the nipples
▪ Inspect and palpate the axillae

9. Heart (Precordium) and Neck

Vessels
▪ Observe the jugular venous pulse
▪ Evaluate jugular venous pressure
▪ Auscultate the carotid arteries if the client is
middle-aged or older
▪ Palpate the carotid arteries
▪ Inspect apical pulse

_______________________ / _________ | 3
 Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES
▪ Palpate the apical impulse
▪ Auscultate heart rate and rhythm
▪ If irregular rhythm is detected, auscultate for
a pulse rate deficit
▪ Auscultate for extra heart sounds
▪ Auscultate for murmurs

10. Peripheral Vascular System

▪ Observe arm size and venous pattern and
look for edema
▪ Palpate the client’s fingers, hands, and
arms, and note the temperature
▪ Palpate to assess capillary refill time
▪ Palpate the radial pulse
▪ Palpate the brachial pulses if arterial
insufficiency is suspected
▪ Palpate the epitrochlear lymph nodes
▪ Perform the Allen test
▪ Inspect legs from the toes to the groin
▪ Inspect distribution of hair
▪ Inspect for lesions or ulcers
▪ Inspect leg for edema
▪ Palpate edema
▪ Palpate bilaterally for temperature of the feet
and legs
▪ Palpate the superficial inguinal lymph nodes
▪ Palpate the popliteal pulses
▪ Palpate the dorsalis pedis pulses
▪ Palpate the posterior tibial pulses
▪ Inspect for varicosities and thrombophlebitis
11. Abdomen
▪ Observe the coloration of the skin
▪ Note the vascularity of the abdominal skin
▪ Note any striae
▪ Inspect for scars
▪ Assess for lesions and rashes
▪ Inspect the umbilicus
▪ Observe umbilical location
▪ Assess contour of umbilicus
▪ Inspect abdominal contour
▪ Assess abdominal symmetry
▪ Inspect abdominal movement when the
client breathes
▪ Observe aortic pulsations
▪ Observe for peristaltic waves
▪ Auscultate bowel sounds

_______________________ / _________ | 4
Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES
▪ Auscultate for vascular sounds
▪ Listen for venous hum
▪ Auscultate for a friction rub over the liver and
spleen
▪ Perform blunt percussion on the liver and the
kidneys
▪ Perform light palpation
▪ Deeply palpate all quadrants to delineate
abdominal organs and detect subtle mass
12. Musculoskeletal System
▪ Observe gait (base of support, weight-
bearing stability, foot position, stride and
length and cadence of stride, arm swing,
posture)
▪ Inspect and palpate the TMJ (test ROM)
▪ Inspect the sternoclavicular joint for location
in midline, color, swelling, and masses
▪ Observe the cervical, thoracic, and lumbar
curves from the side, then behind.
(test ROM)
▪ Palpate the spinous processes and the
paravertebral muscles on both sides of the
spine for tenderness or pain
▪ Test for back and leg pain
▪ Measure leg length
▪ Inspect and palpate shoulders and arms
(test ROM)
▪ Inspect for size, shape, deformities, redness,
or swelling (test ROM)
▪ Inspect wrist size, shape, symmetry, color,
and swelling (test ROM)
▪ Perform Phalen’s test & Tinel’s sign (for
carpal tunnel syndrome)
▪ Inspect size, shape, symmetry, swelling, and
color of hands and fingers (test ROM)
▪ Inspect symmetry and shape of the hips
(with the client standing) (test ROM)
▪ Inspect symmetry and shape of the knees
(with the client standing) (test ROM). Palpate
for tenderness, warmth, consistency, and
nodules
▪ Palpate ankles and feet for tenderness, heat,
swelling, or nodules (test ROM)

_______________________ / _________ | 5
 Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES

13. Neurologic System

▪ Test CN I (olfactory)
▪ Test CN II (optic)
▪ Test CN III (oculomotor)
▪ Test CN IV (trochlear)
▪ Test CN V (trigeminal)
▪ Test CN VI (abducens)
▪ Test CN VII (facial)
▪ Test CN VIII (acoustic / vestibulocochlear)
▪ Test CN IX (glossopharyngeal)
▪ Test CN X (vagus)
▪ Test CN XI (spinal accessory)
▪ Test CN XII (hypoglossal)
▪ Note any unusual involuntary movements
▪ Evaluate gait and balance
▪ Perform the Romberg test
▪ Assess coordination
▪ Assess rapid alternating movements
▪ Perform the heel-to-shin test
▪ Assess light touch, pain, and temperature
sensations
▪ Test vibratory sensation
▪ Test sensitivity to position
▪ Assess tactile discrimination (fine touch)
▪ Test point localization
Test deep tendon reflexes:
▪ Test biceps reflex
▪ Test brachioradialis reflex
▪ Test triceps reflex
▪ Test patellar reflex
▪ Test Achilles reflex
▪ Test ankle clonus
Test superficial reflexes:
▪ Assess plantar reflex
▪ Test abdominal reflex
▪ Test cremasteric reflex (male)
Tests for Meningeal Irritation or
Inflammation:
▪ Test for Brudzinski’s sign
▪ Test for Kernig’s sign
14. Male Genitalia and Rectum
▪ Inspect the base of the penis and pubic hair
▪ Inspect the skin of the shaft
▪ Palpate the shaft
▪ Inspect the foreskin
▪ Inspect the glans
▪ Palpate the urethral discharge
_______________________ / _________ | 6
 Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES
▪ Inspect the size, shape, and position of the
scrotum
▪ Inspect the scrotal skin
▪ Palpate the scrotal contents
▪ Inspect for inguinal and femoral hernia
▪ Palpate for inguinal hernia and inguinal
nodes
▪ Inspect the perianal area (lumps, ulcers,
lesions, redness, rashes, fissures,
thickening of the epithelium)
▪ Inspect the sacrococcygeal area
▪ Palpate the anus
▪ Palpate the rectum
▪ Inspect the stool
15. Female Genitalia and Rectum
▪ Inspect the mons pubis
▪ Observe and palpate inguinal lymph nodes
▪ Inspect the labia majora and perineum
▪ Inspect the labia minora, clitoris, urethral
meatus
▪ Palpate the Bartholin’s glands
▪ Palpate the urethra
▪ Inspect the size of the vaginal opening and
the angle of the vagina
▪ Inspect the cervix
▪ Inspect the perianal area (lumps, ulcers,
lesions, redness, rashes, fissures,
thickening of the epithelium)
▪ Palpate the anus
▪ Inspect the stool

References: 1. ______________________________________
2. ______________________________________
3. ______________________________________
Evaluation Tool:
UNACCEPTABLE SATISFACTORY EXCEPTIONAL REMARKS
Physical Assessment and Review of 1-7 8-12 13-20
Systems Incomplete; majority of pertinent normal and Lacking some details but majority Complete; addressed all
abnormal findings are missing of pertinent normal and systems related to the
abnormal findings are noted chief complaint

_______________________ / _________ | 7
 Mindanao State University – Iligan Institute of Technology
COLLEGE OF HEALTH SCIENCES
Reminders:
o Evaluate the past and present health state of each body system
o Double –check in case any significant data were omitted in the Present Illness section
o Items within each system are not inclusive, and only the most common symptoms are listed.
o When recording information, avoid writing “negative” after the system heading. You need to record the presence or absence of all symptoms;
o Avoid recording the word “normal” for normal findings. eg. do not record: “Liver palpation is normal” instead record: “Liver span 10 cm in right MCL and 4 cm in MSL. No tenderness on palpation”
o Use phrases instead of sentences to record data: ex: avoid “The client’s lung sounds were clear both in the right and left lungs” instead record: “Bilateral lung sounds clear”
o Record data findings, not how they were obtained: eg. do not record “Client was interviewed for past history of high BP and BP was taken” instead record: “Has 3-year history of hypertension treated with
medication. BP sitting right arm 140/86, left arm 136/86”
o A variety of systematic approaches may be used: head-to-toe, major body systems, functional health patterns, or human response patterns. No matter which approach is used, general rules apply”
o Avoid documenting with general nondescript or non-measurable terms such as normal, abnormal, good, fair, satisfactory, or poor, instead, use specific descriptive and measurable terms (eg. 3 inches in diameter,
red excoriated edges, with purulent yellow drainage) about what you inspected, palpated, percussed, and auscultated

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