Z Score,T Score, Percential Rank and Box Plot Graph
Physical examination
1. Page 1 of 5 | Physical Examination.
TRIBHUVAN UNIVERSITY
INSTITUTE OF MESDICINE
NURSING CAMPUS MAHARAJGUNJ
BACHOLER OF NURSING SCIENCES PROGREAMME
2014
PHYSICAL EXAMINATION
By: Supervised by:
PATIENT’S PROFILE:
BIOGRAPHICAL DATA OF PATIENT:
Name of the patient :
Address :
Age :
Sex :
Age group :
Religion :
Occupation :
Education :
Marital status :
Ward :
Bed number :
IP number :
Date of Admission :
Attending doctor :
Provisional diagnosis :
Chief complain:
History of present illness:
History of past illness:
2. Page 2 of 5 | Physical Examination.
PHYSICAL EXAMINATION Date of examination:
General survey:
Examination Findings
Gait
General state of health
Nutritional status
Behavior
Cleanliness
Orientation
Height & Weight
BMI
Vital signs:
B.P :
Pulse :
Respiration :
Temperature :
Spo2 :
Skin
Examination Findings
Inspection
All over the body for color
Any patches or lesions or any evidence of
itching.
Wrinkles
Edema
Excessive sweating or dehydration
Hair distribution
Cleanliness
Evidence of injury
Palpation
Temperature
Edema
Dehydration
Texture
Lymph Nodes:
Examination Findings
Inspection
Redness or enlargement of lymph nodes
Palpation
Enlargement
Tenderness
Head and face:
Examination Findings
Inspection
Shape and size
Swelling, injury on head
Face for movement of
two sides
3. Page 3 of 5 | Physical Examination.
Palpation
Swelling, tenderness and
Depression.
Percussion
To sinuses for tenderness
Eye:
Examination Findings
Inspection
Eye for bulges
Eyelids
Palpebral Conjunctiva.
Bulbar conjunctiva
Cornea
Sclera
Pupils
Eye movements
Accommodation
Visual acuity
Ear:
Examination Findings
Inspection
External ear for location
Pinna for any lump or lesion
External auditory canal for any
redness discharge, mass,
Foreign body or cerumen.
Mastoid area for redness or
Swelling
Palpation
Pinna
Skin flap
Mastoid area
Note: Weber and Rinne test:
Nose:
Examination Findings
Inspection
Nose for location
Nostrils
Nasal septum
Nasal canals
Smelling
Mouth and Throat:
Examination Findings
Inspection
Lips
Mucous membrane
Gums
Teeth
Tongue
Throat/tonsils
Swallowing difficulty
Smell
4. Page 4 of 5 | Physical Examination.
Neck:
Examination Findings
Inspection
The neck position
For enlargement of thyroid gland
Ability to move neck
Back of neck for lump or
Tenderness
Palpation
Back of neck for tenderness
Thyroid gland for tenderness
Chest and lungs:
Examination Findings
Inspection
The shape and size
Symmetry
Expansion during breathing
Intercostals spaces
Cough
Palpation
Chest wall for tenderness, mass
lumps, or depression
The chest for expansion
Chest fremitus
Percussion
The front and back of the chest.
Auscultation
The front and back of chest.
Heart:
Examination Findings
Inspection
Neck veins
Percussion
Heart
Auscultation
Heart sound in aortic, pulmonary,
tricuspid and bicuspid area
Abdomen:
Examination Findings
Inspection
Shape, size, scars, swelling,
and distended blood vessels
Auscultation
Bowel sounds
Percussion
In all areas
Palpation
All areas of abdomen
Liver
Spleen
5. Page 5 of 5 | Physical Examination.
Kidneys
Anus:
Genitalia:
Arms and legs:
Examination Findings
Inspection
Arms and legs for symmetry, edema
or lesions.
Palpation
Arms and legs for edema
Musculo skeletal system:
Examination Findings
Inspection
Muscles and joints
Joint movements
Patient’s spine
.
Palpation
Patient’s neck, shoulder, elbows, knees
ankle joints for swelling, tenderness
and temperature.
Nervous system:
Examination Findings
Muscle strength
Sensation
Coordination
Reflexes
Abnormal findings: