Physica examination tamplate

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: