This document provides guidance on performing a physical examination, including assessments of various body systems and functions. It describes examining the patient's vital signs, general appearance, gait, nutritional status, behavior, cleanliness, speech, skin, nails, head, face, sinuses, eyes, ears, nose, mouth, and throat. For each area, it lists normal findings and potential abnormal findings to note during the examination. The examination involves inspection, palpation, and specific tests of functions like vision, hearing, and neurological responses.

1. Physical examination
Vital signs:
Height:
Weight:
General appearance:
Gait: assess the gait and posture in sitting, standing and walking position. Normal: walks straight,
relaxed, erect posture. Abnormal: limp gait and bent, twisted, curved posture
General state of health: observe the facial expression and sign of distress. Normal: cheerful, active
and appears healthy. Abnormal: sad, tired, weak appearance
Nutritional status:
 Observe the body build, height and weight in relation to the client's age and health. Normal:
appears well nourished. Abnormal: cachectic, thin, generalized fat in whole body (obese),
truncal fat with relatively thin limbs which may be seen in Cushing's syndrome
 BMI: weight in kg / height in meter square (normal: according to WHO: 18.5 – 24.9 kg/m2.
According to Asian category: 18.5 – 22.9 kg/m2)
Behavior: assess the behavior of patient during history taking, taking, caring. Normal: appropriate
reaction to the situation. Abnormal: unusual behavior, unexpected shaking movement, gestures,
restlessness
Cleanliness: assess the patient's clothes, hygiene. Normal: good hygiene, clean clothes, well
groomed and appropriate to the situation. Abnormal data: dirty clothes, poorly groomed
Speech: assess the patient speech (pace, pitch, clarity and spontaneity) while taking with the
patient. Normal: normal (140 – 160 words per minute), spontaneous, clear. Abnormal: Fast speech
may be seen in hyperthyroidism, lack of spontaneity in depression, asthma. Slow, thick, hoarse
voice in myxedema (severe form of hypothyroidism)
Skin:
Inspect the skin for
Color: note the color changes all over the body or in a localized area. Normal: Color varying from
the black, brown or fair depending upon the genetic factor, Uniform color all over the body, No
pallor, redness or yellowness. Abnormal: Pallor due to anemia, Peripheral cyanosis (seen on hand,
feet) may be due to anxiety, cold exposure and venous obstruction, Loss of skin pigment (white
patches) may be seen in vitiligo and albinism; yellow color may be seen in jaundice
Any patches or lesions or any evidence of itching as shown by scratching. Normal: skin free of
lesions or abrasion. Abnormal: skin patches, lesions or itching present
Excessive sweating or dehydration: observe the patient's hand, axilla, face for excessive sweating
and dryness

2. Evidence of injury: inspect the skin for the scar marks which may be due to injury, surgery etc.
Normal: no bleeding, bruising or laceration of skin. Abnormal: bleeding, bruising or laceration of
skin
Palpation of skin:
Temperature: feel it with the back of fingers. Normal: warm skin, even temperature. Abnormal:
generalized warmth which may be seen in fever, hyperthyroidism and coolness in hypothyroidism,
local warmth in inflammation
Texture: feel the skin for smoothness. Normal: smooth, soft skin. Abnormal: dry and roughness in
hypothyroidism
Edema: assess the edema by pressing in the medial part of the tibia 2.5 cm above the medial
malleolus with the thumb finger or index and middle finger for at least 15 seconds. Check the
edema in ankles and legs. Normal: quickly depression recovers or no depression. Abnormal:
depression recovers slowly and edema is present.
Dehydration: Check the elasticity of skin by pinching the skin just below the clavicle in adults and
the abdominal skin in children, between the thumb and index finger, pulling it and quickly
releasing it. Normal: the skin quickly comes back to its previous state. Abnormal: comes back to
its previous state slowly
Nails and Hands:
Inspect the color, length, hygiene and peripheral cyanosis on nails: normal: pinkish, clean and
trimmed nails. Abnormal: redish – brown lines on the fingers and toe nails. Bluish nails and hand
may be seen in peripheral cyanosis.
Clubbing: assess the clubbing by opposing 2 index fingers which are held back to back against
each other. Normal: a diamond shaped space is formed between the nail beds and the nails of the
2 fingers. Abnormal: a diamond shaped space is not formed between the nail beds and the nail of
the 2 fingers.
Capillary refill time: press the edge of the nail to blanch and then release the pressure quickly.
Normal: restoration of the blood in the nails within less than 3 seconds. Abnormal: restoration of
blood within more than 3 seconds
Look for asterixis: ask the patient to hold out his arms with the hand extended at the wrists and
look for a jerky, flapping tremor (asterixis) of the hand. Normal: No tremors of the hand.
Head:
Scalp: inspect the scalp for scaliness, lumps or other lesions. Normal: no scaliness, lumps or other
lesions. Abnormal: redness and scaling may be seen in seborrheic dermatitis, psoriasis

3. Skull: inspect for shape and size. Normal: round and symmetrical. Abnormal: enlarged in
hydrocephalus, redness due to injury. Palpate the skull for swelling, tenderness and depression
Hair: inspect the hair color, distribution, cleanliness. Normal: clean hair, color of hair varying
from black brown and white depending upon genetic factor, no use of artificial colors. Abnormal:
Loss of hair (alopecia), dirty, oily and greasy hair. Presence of lice, dandruff
Palpate the hair for changes in hair texture. Normal: smooth hair . Abnormal hair: fine hair in
hyperthyroidism, coarse hair in hypothyroidism
Face
Inspect the face for involuntary muscle movements (twitching of the face), edema, facial weakness
(by asking the patient to smile), rashes and masses. Normal: absence of involuntary muscle
movement, uniform movement of the sides of the face, no edema and masses. Abnormal: twitching
of the face present, one side of the face moves different from the other side indicating one sided
facial paralysis, presence of edema and masses
Sinuses
Inspect the sinuses area for redness
Palpate the sinuses: frontal sinus: palpate the frontal sinuses for tenderness by pressing up from
under the bony brow on each side. Avoid pressure on the eyes. Maxillary sinus: press upon each
maxillary sinus at the cheek bone. Ethmoid sinus: press the ethmoid sinus at the lateral aspect of
the nose. Normal: No tenderness in frontal, maxillary sinuses and ethmoid sinus. Abnormal:
tenderness present
Trans- illumination of the sinuses: The room should be darkened. Then using a strong, narrow
light source, place the light snugly deep under each brow, close to the nose. The light is shield with
the hand.
For frontal sinus: normal: Look for a dim red glow as light is transmitted through the air filled
frontal sinus to the forehead
For maxillary sinus: Ask the patient to open the mouth wide and tilt he head back. Shine the light
downward from just below the inner aspect of each eye or front of maxillary sinus. Look through
the open mouth at the hard palate. Normal: A reddish glow indicates a normal air filled maxillary
sinus
Abnormal for both the sinuses: Absence of glow on one or both sides suggests a thickened mucosa
or secretions in the frontal sinus. It may also indicate the developmental absence of one or both
sinuses.
Eye: Inspection:
Eye for bulges (proptosis)/ sunken eyes, periorbital edema: inspect the eye for bulging. Normal:
no bulges or sunken eye. Abnormal: bulging (proptosis) or sunken eye, absence of peri orbital
edema

4. Eye brows: for color, distribution of hair. Normal: color may vary from black, brown or white.
Equal distribution of brows in both sides. Abnormal: absent or abnormal distribution
Eye lashes: for curving inward or outward, infection, stye. Normal: outward curving of lashes, no
infection, stye, dandruff
Eye lids: for swelling, redness, infection (blepharitis). Normal: no swelling, redness, infection.
Abnormal: swelling, redness, ptosis
Lacrimal apparatus: inspect the lacrimal gland and palpate the lacrimal sac for swelling. Normal:
no lumps, swelling of the sac, infection of the sac (dacryocystitis)
Inspect for the excessive tearing, dryness of the eye
Conjunctiva: pull down the lower eye lid with the help of fingers and ask the patient to look up.
Assess for paleness, discharge, foreign body. Normal: Dark pink in color, no paleness, discharge
and foreign body. It is just moist. Abnormal: Pale palpebral conjunctiva indicate anemia and
redness indicates conjunctivitis
Sclera: Assess the sclera for any color change, injury and dilated blood vessels. Pull up the upper
eye lid with the help of fingers and ask the patient to look down. Normal: White in color with no
or few small blood vessels. Abnormal: Yellow sclera which indicates jaundice
Cornea: inspect the cornea for color and abrasion. Normal: transparent and no abrasion. Abnormal:
cloudy appearance, abrasion
Lens: with or without the light, inspect the cornea of each eye for opacities in the lens. Normal:
clear and transparent lens. Abnormal: opacities (white color) in the lens
Corneal reflex: ask the patient to keep both eyes open gently pull the lower eye lid down while the
patient looks upward. Then lightly touch the edge of cornea wit the corner of cotton. Normal: a
blink response is followed after touching the cornea. Abnormal: there is no response of the eye
after touching the cornea.
Pupil: PERRLA
Inspect the pupils for shape and size. Normal: PE: pupils equal, round, 2- 4 mm in bright light and
4 – 8 mm in dark light. Abnormal: irregular size and shape
The pupil reaction to light: Light a torch from the side of the eye and quickly remove it. Observe
how pupil reacts. Normal: RL: As the torch approaches the eye, pupil constricts and as the torch
is removed the pupils dilate. Abnormal: Pupils remain constricted even after the torch is removed

5. Accommodation or convergence test: Ask the patient to follow the finger or pencil as you move it
in toward the bridge of the nose. Normal: A: good convergence. Abnormal: Poor convergence
which may be seen in hyperthyroidism
Examination of extra ocular muscles: Hold the finger vertically at least 50 cm away from the
patient. Cover the patient’s one eye. Ask the patient to follow the examiner’s finger or pencil as
the examiner sweep through the six cardinal directions of gaze without moving the patients head.
Making a wide H in the air lead the patient’s gaze: Extreme right, To the right and upward, Down
a right, To the extreme left, To the left and upward, Down on the left. Normal: the eye gazes in all
the six direction. Abnormal: the aye cannot gaze in all the six directions, presence of diplopia
(double vision)
Cover test (squint test): Cover one eye of the patient with hand and ask the patient to look at the
light of the torch from another eye and closely observe the uncovered eye for any movements.
Repeat the sequence for the other eye. Normal: the uncovered eye does not move. Abnormal: If it
moves to take up fixation (first moves and then fixes), then that eye is squint, exotropia: eye moves
inward to pick up fixation. esotropia: eye moves outward to pick up fixation.
Visual acuity test: Snellen chart is used to test vision. Position the patient at 20 feet (6 meter) from
the chart. Patient who uses glass should wear them. Cover one eye and ask the patient to read the
chart from the top to down until they cannot read any further. Repeat for the other eye. Snellen
visual acuity is expressed as 6 (the distance at which the chart is read) over the number
corresponding to the lowest line read
Peripheral vision test: Sit at about 1 meter away and ask the patient to cover one eye ask to look at
the examiners eye directly opposite. Close your (examiner) other eye and slowly bring a pencil or
other small test being object from the periphery into the field of vision from the 6 direction and
ask the patient to say” now” “dekhiyo” as soon as it appears. Keep the test object equidistant
between your and patient’s eye so that you can compare the patient’s visual field your own.
Repeat with the other eye
Nystagmus: Hold the finger an arm length from the patient. Then ask the patient to look at your
finger and follow it with his eyes without moving the head. Move your finger steadily to each side
and up and down making a shape of "H". Watch the patient's eyes carefully for jerky movements
on the direction of gaze. Normal: there is no abnormal movement (jerking) of the eyeball when at
extremes of lateral gauze normal eyeball may also show some jerks. Abnormal: jerking of the
eyeball on the direction of gaze
Ear: inspect:
Location: inspect the location of both ear. Normal: The top of the pinna meets or crosses the eye -
occiput line imaginary line drawn from the outer canthus of the eye to the occipital protuberance.
Abnormal: The top of the pinna does not meet or cross the eye – occiput line or low set ear

6. Pinna: inspect the pinna for any lump or lesions. Normal: no lumps or wound, smooth rounded
contour. Abnormal: lump or wound present
External auditory canals: Inspect the external auditory canals with the torch light or otoscope by
pulling the ear up and back in adults for any ear discharge, redness, mass, foreign body, cerumen
(wax). Normal: No discharge, redness, mass or foreign body, slight cerumen present. Abnormal:
Clear blood or yellow discharge, redness, mass, foreign body, excessive cerumen present.
Tympanic membrane: use otoscope / torch light to inspect the tympanic membrane. Normal: Color:
pearly grey, translucent membrane. No perforations, masses, bulging and no tearing of the
membrane. Abnormal: perforations, bulging and masses present.
Palpate the ears by pulling the upper portion of the pinna a little for tenderness and pressing the
mastoid area for any tenderness. Normal: no tenderness while pulling the pinna and pressing the
mastoid bone. Abnormal: tenderness present while pulling the pinna, tenderness behind the ear
maybe present in the otitis media.
Rinne test: Place the base of the lightly vibrating tuning fork on the mastoid bone, behind the ear
and level with the canal. When the patient can no longer hear the sound, quickly place the fork
close to the ear canal and ascertain whether the sound can be heard again. Here “U” of the fork
should face forward which maximize the sound. Normal: the sound is heard longer through air
than through bone (AC>BC). Abnormal: if the sound is not heard from the ear canal after hearing
from the mastoid process then bone conduction is better or longer than air conduction. Record this
as BC > AC. This may be due to conductive hearing loss
Weber test: Place the base of the lightly vibrating tuning fork firmly on top of the patient’s head
or on the mid forehead. Ask where the patient hears it: one or both ear. Normal: the sound is heard
in the midline or equally in both ears. If nothing is heard, try again, pressing the fork more firmly
on the head. Abnormal: The noise is louder in an ear with conductive deafness. In unilateral
sensorineural hearing loss, the sound is better heard in the normal ear.
Nose:
Inspect the location of nose: normal: centrally located. Abnormal: deviated in location.
The nostrils for their size and flaring: normal: Nostrils are uniform in size and do not flare.
Abnormal: Asymmetrical in size or flaring nostril
The nasal septum for any polyps (growths) using light: Normal: no polyp or deviation. Abnormal:
presence or polyps or deviation.
Assess the nasal canals with a torch for redness, discharge, foreign bodies etc. Normal: Dark pink
mucous membrane, no discharge or foreign bodies. Abnormal: Red swollen mucosa inacute
rhinitis; pale mucosa in allergic rhinitis

7. Lightly palpate the external nose to determine any area of tenderness, mass and deviation
Determine the patency of nasal canal: press on each nostril and ask the patient o breath in. normal:
no obstruction. Abnormal: obstruction
Mouth and throat:
Inspect the lip for color, moisture, lumps, cracks or ulcers. Normal: Pink, moist and intact skin, no
bluish discoloration, cracks and ulcers. Abnormal: Lips bluish in color cracks or ulcers present
Inspect the mucous membrane of the mouth for the color, ulcer, nodules, amount of saliva and
central cyanosis at the lips and underside the tongue. Normal: pink, moist mucous membrane, no
ulcer, nodules. Abnormal: Inflammation, swelling, redness or bleeding and central cyanosis
present.
Inspect the gums for inflammation, swelling, redness or bleeding. Normal: Pink, no inflammation,
swelling, redness or bleeding. Abnormal: Inflammation, swelling, redness or bleeding present
Inspect the teeth for the color, caries and missing tooth. Normal: White teeth, no caries and missing
teeth. Abnormal: Brown teeth, presence of caries or missing teeth, yellow plaque (stains)
Inspect the tongue for symmetry, color and papillae. Normal: Symmetrical, pink, moist, papillae
and midline fissure present. Abnormal: Asymmetrical, red, pale, dry papillae or fissure absent
Inspect the throat and note the color and size of the tonsils. Normal: Pink throat and a small tonsil.
Abnormal: Red swollen and yellow discharge from the tonsils
Assess the swallowing difficulty by asking the patient to swallow a sip of water. Normal: difficulty
in breathing. Abnormal: difficulty in breathing
Palpate: using the gloves assess the gums on both sides with fore fingers of the right hand and
check for swelling and tenderness. Normal: no swelling, tenderness. Abnormal data: swelling and
tenderness present.
Palpate: The teeth by moving them with the fore fingers of the right hand for any pain or loose
teeth. Normal: No toothache, no loose tooth.
Smell: The patient’s breathe and note any foul odor or alcohol smell in the breath. Normal: no foul
odor or smell of alcohol. Abnormal: Breath odor of alcohol, acetone in diabetes mellitus,
pulmonary infection, uremia etc
Lymph nodes
Inspect the area of lymph nodes for redness or enlargement: normal: Lymph nodes not visible, no
redness. Abnormal: Enlargement and redness of lymph nodes

8. Palpate for the enlargement and tenderness of lymph node: Normal: Lymph nodes are not palpable
and tenderness. Abnormal: Hard, fixed nodes suggest malignancy, enlargement of a
supraclavicular lymph node especially on the left, suggests possible metastasis from a thoracic or
abdominal malignancy
Neck:
Inspect the neck by asking the patient to sit straight. Observe masses and scars of the neck.
Normal: no tilting of neck or straight neck. Abnormal data: tilting of the head, scar mark of the
thyroid surgery.
Inspect the jugular veins for enlargement by asking the patient to turn the head side. Normal:
jugular veins are not distended or tortuous. Abnormal: distended, tortuous jugular veins.
Inspect the use of accessory muscles: normal: accessory muscles of neck are not used during
respiration. Abnormal: use of accessory muscles present in COPD
Range of motion of neck: ask the patient to move neck up and down and from side to side. Note
any stiffness or tenderness. Normal: Full and smooth range of movement, no stiffness or
tenderness, no swelling or lump. Abnormal: Swelling, tenderness and decreased range of motion
suggests arthritis, Swelling or lump present
Inspect for the enlargement of the thyroid gland. Normal: Thyroid gland not visible and enlarged.
Abnormal: Enlarged thyroid gland
Palpate thyroid gland: Ask the patient to sit with the neck muscles relaxed. Then place the hands
gently on the the neck just above the clavicles with your index finger. Aks the patient to swallow
and feel the thyroid gland as it moves upwards. Note the size, shape and consistency of masses
(goiter). Normal: Thyroid gland is not normally palpable. Abnormal: nodules, irregular mass
present or thyroid gland is palpable, goiter (masses) move upward on swallowing..
Chest:
Place the patient in semi fowler's. Inspect the chest for size and shape: symmetrical and
ellecptical(elongated oval) in shape. Inspect the anterioposterior and lateral diameters of the chest.
Normal: Lateral diameter (side to side) is wider than anterioposterior (front to back) diameter.
Abnormal: Barrel shaped chest (increase antero posterior diameter) may be due to pulmonary
emphysema, Funnel shaped chest: characterized by a depression in the lower portion of the
sternum, Pigeon shaped chest: sternum is displaced anteriorly and increasing anterioposterior
diameter
Inspect the sternum for symmetry and location: Normal: Symmetrical shape, sternum is located at
the midline. Abnormal: Sternum is displaced
Inspect for the intercoastal retraction: see the intercoastal muscles whether they move in (retract)
when the patient breathes in. normal: no intercoastal retraction. Abnormal: retraction at the
intercoastal spaces

9. Palpate the chest for tenderness, lumps, depression along the ribs in a "L" shaped fashion. Normal:
no tenderness, lump or depression along the ribs. Abnormal: tenderness of the chest, lump or
depression along the ribs present.
Tracheal deviation: With the patient directly looking forwards, look for any deviation of the
trachea, gently place the tip of you right index finger into the suprasternal notch and palpate the
trachea. Normal: trachea is at the mid line just above the sternum. Slight displacement to the right
is common in healthy people. Abnormal: Shift of the upper mediastinum causes tracheal deviation.
Chest expansion: Ask the patient to sit in fowler's position and stand behind the patient or turn the
patient on one side. Stand behind the patient and ssess expansion of the lungs by placing your
hands firmly on the patient's chest wall. Your thumbs should almost meet in the midline and place
just over the chest so they can move freely with respiration. Ask the patient to take deep breath.
Your thumbs should move symmetrically apart by at least 5 cm. Normal: Both sides of the thorax
should expand equally during normal breathing and maximal inspiration. Abnormal: Reduced
expansion on one side which indicates abnormality on that side. For e.g. pleural effusion, lung or
lobar collapse, pneumothorax
Tactile fremitus: place palms lightly in between the scapula or just back side of the clavicle and
ask the patient to say "99" or "E". Normal: Vibratory tremors are felt through the bilateral chest
on the palms. The process is repeated downwards from the scapula. Likewise the vibration is
highest in the scapula and decreases downward. Abnormal: vibratory tremors increases when the
lung has excess air (pneumothorax, emphysema) and decreases when the lungs has fluids, masses
(compression, consolidation)
Percussion: (perform posterior percussion first and then anterior so tat patient should not be moved
again and again)
Posterior percussion: Position the patient sitting forwards with their arms folded in front to move
the scapulae laterally. In the scapula region percuss medially just on the side of the vertebra and
move laterally after the scapular region is over. Compare positions the same distance from the
midline on right and left. Normal: resonant sound. Abnormal: hyper resonant sound is seen in
pneumothorax, dull sound is seen in pulmonary consolidation, severe pulmonary fibrosis, pleural
effusion and hemothorax.
Anterior percussion: Ask the patient to sit in semi fowler's position. Percuss in sequence (L shaped)
from just above the clavicle to the 6th intercoastal spaces in the mid clavicular line and 7th
intercoastal space in the midaxillary line comparing areas on the right with corresponding areas on
the left before moving to the next level.
Ausculation of breath sound: Auscultate each side of the lung alternately, comparing findings over
a large number of equivalent positions to ensure that you do not miss localized abnormalities.
Anteriorly from above the clavicle down to the sixth rib, laterally from the axilla to the eight rib,

10. Posteriorly down to the level of 11th rib. Assess the quality and amplitude of breath sounds. Identify
the inspiration and expiration time.
Normal:
• Bronchial sound heard over the trachea are high pitched, harsh sounds with expirations longer
than inspiration (E>I)
• Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center
part of the anterior chest where inspiration equal to expiration
• Vesicular sounds are soft, low pitched and heard best in the base of lungs during inspiration
longer than expiration
Abnormal: Wheezes, ronchi, rales, crackles, crackles and pulmonary friction rub present
Heart:
(inspection and palpation of heart is done in chest examination)
Palpate the apex beat at by placing the hand flat around the 5th intercostal space or just below the
nipple. Palpate for thrill at the apex and both sides of the sternum using the flat of your fingers.
Normal: apex beat is heard normally on the 5th intercostal space. Normally thrill is not heard.
Abnormal: apex beat may be displaced from the mid clavicular line to axillary line or on the 6th
intercostals space which may be seen in hypertension.
Auscultation:
Auscult the aortic area: 2nd intercoastal space just to the right of the sternum, Pulmonic area: 2nd
intercoastal space just to the left of the sternum, Tricuspid area: 4th intercoastal space just to the
left of the sternum, Mitral area: 5th intercoastal space at the mid clavicular line.
Count the heart rate at 5th intercostals space, compare the radial pulse to detect skipped beat by
using stethoscope
Normal: Clear and regular, heart rate between 60 – 80 b/m, No murmur sound present. First (S1)
heart sound (lub) is caused by the closure of mitral and tricuspid valves at the onset of ventricular
systole. Second (S2) heart sound (dub) is caused by the closure of the pulmonary and aortic valves
at the end of ventricular systole. Abnormal: Decreased or inaudible heart sounds irregular or
missed heart beats, heart rate less than 60 or more than 100 b/m.
Female breast
Inspect the size and shape of the breast, visible tortuous veins, swelling and retraction of the breast
along the axilla by exposing it: Normal: breasts are uniform in size and shape. It is the normal for
one beast to be slightly larger than the other. Abnormal: irregular in shapes, visible tortuous veins,
redness, swelling and retraction of the breast. Axilla may be pigmented, rashes may be present.

11. Inspect the nipples for cracks, discharges and whether pointing on the same direction: Normal:
Nipples point to the same direction and everted. No enlargement of veins, no cracks, milky
discharge in pregnant or breastfeeding women. Abnormal: nipples do not point to the same
direction and inverted. Cracks, yellow or bloody discharge
Palpation of breast: Ask the patient to raise her arms above her. Palpate both the breasts in a
circular or spiral motion including the axilla and check for any mass, swelling and tenderness.
Normal: Soft, non tender and often ridge of tissue are felt at the bottom of breast. Abnormal: Hard,
irregular, poorly circumscribed masses suggest cancer.
Male breast: inspect the breast shape, swelling, redness and discharge. Abnormal: A firm disc of
glandular enlargement in a male is called gynecomastia
Abdomen
Inspect the shape, scars, swelling and distended veins on the stomach: Normal: Rounded or flat
and uniform size, no scar, swelling and visible blood vessels in abdomen. Abnormal: Irregular in
shape Abdominal scars present indicating previous injury or surgery. Swelling of abdomen and
distended blood vessels
Auscult the bowel sound: Listen carefully in all 4 quadrants using sthestethoscope. The
stethoscope should be warm as the cold may contract the abdominal muscles. Note whether the
bowel sounds are increased, decreased or absent. Listen in all 4 quadrants for each 1 min. Normal:
Bowel sound (Clicks and gurgling sound) present in all areas in every 5 – 10 seconds. Abnormal:
High pitched tinkling sounds, absence of bowel sound (no bowel sound heard for 5 minutes), loud
rushing sound is heard.
Percussion:
Place the patient in supine position placing the pillows on the knees. Percuss in all the 4 quadrants
and note the areas where dull or tympanic sounds are produced (tympanic sound is heard over gas
filled viscera and dull sound over fluid filled viscera, fecal organs or masses). Normal: scattered
area of tympanic and dull sound. Abnormal: dull sound when excess fluid is present.
Shifting dullness: Percuss from midline out to the flank. Note the tympanic or dull sound. Then
turn the patient on his/her side and pause for 10 seconds. Again percuss the turned side area. Note
the presence/absence of dullness after the patient is moved laterlally. Normal: Scattered area of
tympanic and dullness sound. Shifting dullness is absent. Abnormal: Shifting dullness is a sign of
fluid in abdomen. First dull sound is heard in supine position percussion and then tympanic sound
is heard in the lateral position percussion.
Fluid thrill: if the abdomen is tensely distended and you cannot certain whether ascites is present,
feel for a fluid thrill. Place the palm of your left hand flat against the left side of the patient's
abdomen and ask the assistant or patient to place the edge of his hand on the midline of the
abdomen. This prevents transmission of impulse via the skin rather than through the ascites. Then

12. flick a finger of your right hand against the right side of the abdomen and feel a ripple (thrill of
fluid). Normal: thrill of fluid is absent. Abnormal: fluid thrill is present.
Abdominal reflex: expose the abdomen and then brush lightly in each quadrant with the help of
back of reflex hammer or key or any blunt stick. Normal: the abdominal muscle constricts on
brushing the abdomen. Abnormal: no abdominal relfex
Palpation of abdomen: Light palpation: palpate with your fingers for abdominal masses,
tenderness. Normal: no abdominal masses, tenderness absent.
Deep palpation:
Liver palpation: Place your hand flat on the skin of the right iliac fossa. Point your fingers upwards
and your index and middle fingers lateral to the rectus muscle, so that your fingertips lie parallel
to the rectus muscle. Move your hand progressively up the abdomen, 1 cm at a time, between each
breath the patient takes, until you reach the costal margin or detect the liver edge. Note any
enlargement or tenderness. If enlarged, estimate the amount of enlargement beyond the right
coastal margin. Express it in centimeters. Normal: No abdominal mass and tenderness. Liver is
not usually palpable but in thin people it may be palpable immediately below the coastal margin
as a smooth structure with a regular contour and a firm, sharp edge. Abnormal: Liver palpable as
soft or hard edge or irregular in contour
Spleen palpation:
Place the hand over the iliac crest of the right side and move the hand diagonally towards the
patient’s umbilicus. Move the hand diagonally upwards 1 cm at a time between each breath the
patient takes towards the left hypochondrium. Move the hand until you feel the costal margin along
its length. If you cannot feel the splenic edge, palpate with your right hand, placing your left hand
behind the patient’s left lower flank region. . Note any enlargement or tenderness. Normal: spleen
is not palpable. Abnormal: spleen is palpable
Kidneys palpation:
Keep the patient in the supine position. Place the left hand on the patient’s back between the lowest
ribs (12th rib). Ask the patient to take deep breaths. Press firmly with the right hand on the lower
quadrant of stomach and try to feel the kidney. Feel on the left side too. Note the enlargement or
tenderness on kidneys. Normal: Kidneys are not palpable and tender. Abnormal: Kidneys enlarged
and tender
Anus: Inspect the anus for any irritation, crack, fissures or enlarged vessels. Normal: No irritation,
fissure, cracks or enlarged blood vessels in the anus. Abnormal: Presence of anal irritation, anal
fissure and enlarged anal blood vessels.

13. Male genitals: Inspect the penis and scrotum: inspect the penis for any sores or lumps. Normal:
No sore, lump, swelling, redness or lesions. Abnormal: Presence of sore or lumps swelling,
redness or lesions of scrotum
Palpate the testes for enlargement or tenderness of scrotum. Normal: No enlargement, tenderness
or scrotum. Testes are equal in size, no tenderness. Abnormal: Enlargement or tenderness of
scrotum, one testis is larger than the other
Female genitals: Inspection of labia: Inspect the labia for color, redness or swelling, the urethral
orifice for redness or discharge as well as any discharge or bleeding from the vagina. Normal:
Labia are of same color and size. No redness or swelling of the labia. No redness or discharge at
the urethra. No unusual discharge from the vagina, no bleeding from the vagina (except during
menstruation). Abnormal: Red or swollen labia, redness or discharge at urethra, unusual discharge
and bleeding (except during menstruation).
Musculoskeletal system:
Inspect the muscles and joints: Ask the patient to stand. If the patient can and inspect his neck,
shoulder, arms, hands, hips, knees, legs, ankle and feet. Note any bone or joint deformity, joint
redness, swelling or muscle wasting. Normal: No bone or joint deformity (nodes, ulnar deviation
etc), no redness, swelling of joints, no muscle wasting. Abnormal: Presence of bone deformity,
joint deformity, joint redness or swelling, muscle wasting
Palpate the musculoskeletal system: e.g. the patient’s neck, shoulder, elbows, writ, fingers, hips,
knees, ankles, toes one by one and feel for swelling, tenderness and temperature. Normal: No joint
swelling or tenderness, normal temperature. Abnormal: Joints swelling suggests rheumatoid
arthritis, increased temperature over a joint
Joint movement (Range of Motion): Ask the patient to move his neck, shoulder, elbows, wrists,
fingers, hip, knees ankles and toes one by one in all possible directions. Compare one side with
the other side Normal: Able to move joints freely and no sign of pain while moving joints.
Abnormal: Conditions that impair range of motion include arthritis, inflammation of the tendon
sheaths and fibrosis in palmer fascia. Limited movement of the joint and signs of pain present
when moving the joint.
Make a fist with each hand, thumb across the knuckles and then extend and spread the fingers.
Normal: A person able to make tight fists and extend and spread the fingers smoothly and easily.
Spine: Inspect the patient’s spine. Stand behind the patient and note its placement and curvature.
Normal: A person able to make tight fists and extend and spread the fingers smoothly and easily.
Spine is in the midline. Spine slightly curved out from the neck and gradually curved inward at the
waist. Abnormal: Lateral deviation of spine (kyphoscoliosis), increased curvature of spine
(kyphosis) or flattening of curves of the spine (lordosis) and decreased spinal mobility in
osteoarthritis.

14. Neurological system:
Assess the orientation: By asking the patient about the current time, place and pointing out to a
person and asking “who is he/ she?” Normal: Patient says the correct current time, place of stay
and the person pointed at. Abnormal: Patient cannot say the correct current time, place of stay and
the person pointed at
Muscle strength: Ask the patient to lift the hand, leg or the body part in which you want to assess
the strength. Normal: Equal strength in both hands and feet. No muscular weakness. Abnormal:
Muscular weakness in one or both hands and feet.
Scoring of the strength:
0= No muscle contraction visible, 1= Flicker of contraction but no movement, 3= Joint movement
when the effect of gravity eliminated, 3= Movement against the gravity but not against examiners
resistance and 4= Movement against resistance but weaker than normal, 5= normal power
Sensation: ask the patient to close his eyes. Brush the skin of his face, arms, hands, thighs and legs
with a piece of cotton and instruct the patient to signal when he feels light brush of the cotton.
Normal: Feels light brush of the cotton equally on both sides of his body. Abnormal: Loss of
sensation to light brush i.e. does not feel light brush of the cotton equally on both sides of his body
Coordination of movement: ask the patient to button his shirt or to tie his shoes or do nose finger
test: in nose finger test. Sit at least a arm distance from the patient straightly. Examiner points the
finger and the patient is asked to touch his own nose and then the examiner's finger with the index
finger. It is repeated for 3 – 4 times by changing the location of examiner's target finger. Normal:
Coordinated movements. Abnormal: Uncoordinated movement
Reflex test
Superficial reflex:
 Corneal reflex
 Abdominal reflex
 Planter reflex
Babinski (planter) reflex: Run a blunt object along the lateral border of the sole of the foot towards
the toe (from heel of the feet to the ball of the foot towards the big toe). Observe the response.
Normally all the five toes bend downwards. This reaction is negative babinski. In an abnormal
(positive) babinski response the toes spread outward and the big toe moves upward
Deep tendon reflex:
Biceps reflex: The forearm should be supported, either resting on the patient's thighs or resting on
the forearm of the examiner. The arm is midway between flexion and extension. Place your thumb
firmly over the biceps tendon, with your fingers curling around the elbow, and tap briskly. The
forearm will flex at the elbow or the muscle just above the bicep tendon contracts. Compare to the
other hand.

15. Triceps reflex: Support the patient's forearm by cradling it with yours or by placing it on the thigh,
with the arm midway between flexion and extension. Identify the triceps tendon at its insertion on
the olecranon, and tap just above the insertion. There is extension of the forearm or contraction of
the muscle just above the triceps tendon. Compare to the other hand.
Knee jerk reflex: Let the knees swing free by the side of the bed, and place one hand on the
quadriceps so you can feel its contraction. If the patient is in bed, slightly flex the knee by placing
your forearm under both knees. There is contraction of the quadriceps along with extension of the
lower leg. Compare to the other knee.
Achilles tendon reflex: The ankle reflex is elicited by holding the relaxed foot slightly flexing with
one hand and striking the Achilles tendon with the hammer and noting plantar flexion. Compare
to the other foot.