Physical examination, Fundamentals of Nursing

Physical Examination
Prepared by: Pooja Koirala
Lecturer
NMCTH

Physical examination
• Physical examination is an important tool in
assessing the patient’s health status.
• About 15% of the information used in the
assessment comes from the physical
examination.
• It is performed to collect objective data and to
correlate it with subjective data.

• It is a systematic data collection method that
uses the senses of sight, hearing, smell and
touch to detect health problems
• The physical examination, thoughtfully
performed, should yield 20% of the data
necessary for the patient diagnosis and
management.

Purposes of physical examination
• To obtain baseline data about the client’s
functional abilities
• To obtain data that will help the nurse establish
nursing diagnosis and plan the care
• To evaluate the physiologic outcomes of health
care and thus the progress of a client’s health
problem

Purposes of physical examination
cont…
• To make clinical judgments on a client’s health
status
• To determine the client’s eligibility (suitable
fitness) for health insurance, military service

General guidelines / principles for
physical examination
Mnemonics: WIPER
• W: wash the hands
• I: Introduce yourself to the patient
• P: permission, P: Pain
• Expose: expose the necessary parts of the patient.
Ensure adequate privacy
• R: Reposition the patient. In this examination the
patient should be lying flat with one pillow under
the head.

General guidelines / principles for
• It should proceed in an orderly fashion with a
minimum of required position shifts by the
patient.
• Generally cephalocaudal approach is used.
• In case of infant and child, examination of heart
and lungs function should be done before the
examination of other body parts, because as the
infant starts crying, his / her respiratory and heart
rate may change.

Anatomical area Patient Examiner
Vital signs, general
inspection
Sitting or reclining (lie
down)
Standing before patient or
at right bed side
Head and neck Sitting Standing before patient
Anterior torso (trunk) Sitting Standing before patient
initially, later behind the
patient
Posterior torso Sitting At patient’s side
Anterior chest and
abdomen
Supine Before the patient
Male genitalia Standing Before the patient
Gait, station,
coordination
Variable positions Behind the patient
Female genitalia Reclinining on
examining table, draped,
knees flexed, legs
adducted, feet in stirrups
Sitting on chair at times or
standing

Equipment required for physical
examination
• A tray containing:
– Paper bag with cotton
– Sphygmomanometer
– Flashlight
– Stethoscope
– Lubricating jelly
– Thermometer tape measure
– Oto – opthamlmoscope

Equipment required cont…
• Weighing machine
• Tongue depressors
• Pocket eye chart
• Tuning fork (128Hs)
• Gloves (for rectal examination)
• Reflex hammer

Methods of physical examination
• A systematic approach should be used while doing
• Generally cephalo caudal approach e.g. head to toe
approach is used
• But the flexibility may be used as per the need of the
patient.
• The procedure can vary according to the age of the
individual, severity of the illness. The preferences often
nurse, location of the examination and the agency’s
priorities and procedures

• In children examination of heart and lung’s
function may be done before the examination
of other body parts.

Steps of physical examination
•Inspection
•Palpation
•Percussion
•Auscultation

Inspection
• It is the visual examination, which by assessing
the sense of sight to discover some signs of
illness.
• The nurse inspects with the naked eyes and with a
lighted instrument such as an otoscope.
• Visual inspection helps to assess moisture, color,
texture of the body surfaces as well as shape, size,
symmetry of the body
• Inspection reveal more information than other
method

Palpation
• Palpation follows inspection
• It is the examination of the body using the sense of
touch
• Different parts of the hands are used for different
sensations such as temperature, texture of skin,
vibration, tenderness etc
• Finger tips are used for fine tactile details, the back of
fingers for temperature and the flat of the palm and
fingers for vibrations such as cardiac thrill
• All the assessable parts of the body should be palpated

Palpation cont…
• Palpation may be either light or deep and is
controlled by the amount of pressure applied to
the fingers or hand
• Light palpation is done with the hand parallel
to the floor with the fingers together as in
palpation of the abdomen
• The palm lies lightly on the pat and the fingers
depress the part about ½ on 1 cm deep. Light
palpation of structure such as abdomen
determines the area of tenderness.

Palpation cont…
• Deep palpation is performed by pressing the
distal half of the palmer surface of the fingers
into the abdominal wall.
• It is used to examine the condition of organs
•
• It also helps to obtain specific information
about he mass detected by light palpation.

Palpation cont…
• Palpation is used to determine
– Texture e.g. the hair
– Vibration e.g. of a joint
– Position e.g. size, consistency and mobility of
organs or masses
– Distention e.g. of the urinary bladder
– Pulsation
– The presence of pain upon pressure

Principles of palpation
• You should have short fingernails
• You should warm your hands prior to placing
them on the patient
• Encourage the patient to continue to breathe
normally throughout the palpation
• If pain is experienced during the palpation
discontinue the palpation immediately
• Inform the patient where, when and how the touch
will occur, especially when the patient cannot see
what you are doing

Percussion
• It is the act of striking the body surface to elicit
sounds that can be heard or vibrations that can
be felt when they are tapped with the fingers.
• They are of two types
– Direct percussion
– Indirect percussion

Process of indirect percussion
• Put the middle finger of her left hand against the
body part to be percussed
• Tap the end joint of this finger with the middle
finger of the right hand. Move the right hand from
the wrist to tap the left middle finger
• Give two or three taps at each area to be
percussed
• Compare the sound produced at different areas.

Types of sound produced in percussion
1. Tympanic: it is a musical or drum like sound
produced from an air filled stomach
2. Resonance: it is a hollow sound such as that
produced by lungs filled with air (normal
lungs sound)
3. Hyper resonance: it is not produced in the
normal body. It is described as booming and
can be heard over the emphysematous lungs

• Dullness: it is the thud like sound produced b
dense tissue such as the liver, spleen, heart etc
• Flatness: it is an extremely dull sound
produced by very dense tissue, such as muscle
or bone

Auscultation
• Auscultation means listening to the sounds
transmitted by a stethoscope.
• The stethoscope is used to listen to the heart,
lungs and bowel sounds
• Auscultation may be direct and indirect.
• The stethoscope should be always be placed on
naked skin because clothing obscures sounds.

Steps of doing physical examination
• Take clinical measurements like height, weight
and vital signs
• Prepare the patient for physical examination
• Explaining the purposes and procedure for
• Telling the patient how long the examination will
take
• Asking him/ her to urinate
• Arranging for a quiet, private area for assessment

Steps of doing physical examination
cont…
• Asking the patient to remove his clothes and
giving him a drape to cover
• Inspect the patient’s general appearance
• Assess the physical status of the patient in a
systematic way by using various methods of
• After completing the physical examination, allow
the patient to put on his clothes
• Explain the findings to the patient
• Record the relevant findings of the physical
examination on the patient’s assessment form.

Physical examination: General appearance
Use Inspection
Examination Normal data Abnormal data
Gait
If patient is in bed,
assess posture
Walks straight
(Assess while
standing)
Limps
General state of
health
Cheerful,
active and
appears healthy
Sad, tired, weak appearance
Stature: note the
general bodily
proportions and
look for any
deformities
Very short stature in Turner
syndrome, renal disease,
hypopituitarism (dwarfism),
long limbs in marfan’s syndrome

Nutritional status Appears well
nourished
•Obese or thin.
•Generalized fat in
simple obesity
•Truncal fat with
relatively thin limbs
in Cushing
syndrome
•BMI:

Behavior Appropriate
reaction to the
situation
Unusual behavior,
unexpected shaking
movement, gestures,
restlessness
Cleanliness Good hygiene,
clean clothing, well
groomed
Dirty clothes, poorly
groomed
Speech (listen for
the pace of speech
and its pitch,
clarity and
spontaneity
Fast speech may be due
to hyperthyroidism,
lack of spontaneity in
depression, asthma.
Slow, thick, hoarse
voice of myxedema

Skin: use inspection and palpation. Start
from head then proceed down
Inspect the skin
for
a. The color: note
the color changes
all over the body
or in a localized
area.
-Color varying from
the black, brown or
fair depending upon
the genetic factor
-Uniform color all
over the body
-No pallor, cyanosis,
redness or
yellowness
•Pallor due to anemia
•Peripheral cyanosis (seen on
hand, feet) include anxiety,
cold exposure and venous
obstruction
•Central cyanosis (seen on
lips and tongue) include lung
disease, congenital heart
disease
•Vitiligo, albinism, yellow
color , scar marks

Inspection of skin
b. Any patches or
lesions or any
evidence of
itching as shown
by scratching
-Skin fee of
lesions or
abrasion
Skin patches,
lesions or itching
present
c. Edema -No edema Edema
d. Excessive
sweating or
dehydration
-No excessive
moisture or
dryness
- Dryness in
hypothyroidism,
oiliness in acne

Skin cont…
e. Evidence of injury No bleeding,
bruising or
laceration of skin
Bleeding, bruising
or laceration of skin
Palpate the skin for
a. temperature: feel
it with the back of
fingers
Warm skin, even
temperature
Generalized warmth
in fever,
hyperthyroidism and
coolness in
hypothyroidism,
local warmth in
inflammation

Palpate the skin for cont…
Examination Normal data Abnormal
data
b. texture: feel the skin for
smoothness
Smooth, soft
skin
Roughness in
hypothyroidis
m
c. edema: presses the skin with the
index and middle finger and then
leave and watch the depression
Quickly
depression
recovers
Depression
recovers
slowly
Dehydration: dehydrated skin loses
its elasticity. 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
Elastic skin: the
skin quickly
comes back to
its previous
state
Comes back
to its
previous state
slowly

• ..videosy2mate.com -
pitting_edema_example_adkrWQ8sWFU_108
0p.mp4

Head
Inspection
Scalp: scaliness,
lumps or other
lesions
No scaliness, lumps or other
lesions
Redness and scaling in
seborrheic dermatitis,
psoraisis
Skull: general size
and contour of the
skull. Note any
deformities, lumps
or tenderness
Enlarges skull in
hydrocephalus
Hair: Hair
distribution, color,
cleanliness
•clean, smooth and dry hair
•color of hair varying from
black brown and white
depending upon genetic
factor, no color change in the
hair
Loss of hair, dirty hair,
changes in hair, e.g.
fine hair in
hyperthyroidism,
coarse hair in
hypothyroidism

Examination of Head
Palpation:
•swelling,
tenderness and
depression
•Hair texture
No swelling,
tenderness and
depression
Silky, clean
Swelling,
tenderness and
depression
Dry, oily, greasy

Examination of face
Face: involuntary
movements, edema
and masses
Uniform movement of
the sides of face, no
edema and masses
One side of the face
moves different from
the other side
indicating one sided
facial paralysis

Sinuses
Use inspection and palpation
Palpate the sinuses: palpate the
frontal sinuses for tenderness by
pressing up from under the bony
brow on each side.
Avoid pressure on the eyes. Then
press upon each maxillary sinus
No
tenderness in
frontal and
maxillary
sinuses
Local tenderness,
together with symptoms
such as pain, fever and
nasal discharge,
suggests acute sinusitits
involving the frontal or
maillary sinuses
Trans illumination of the sinuses
•It is not done routinely
•The room should be darkened.
•Using a strong, narrow light source,
place the light snugly deep under
each brow, close to the nose.
Shield the light with your hand .

maxillary_sinus_transillumination_Z-
CYWdc73IQ_360p.mp4

frontal_sinus_transillumination_8Lo3bENDqzs
_360p.mp4

Examination Normal
data
Abnormal
data
Look for a dim red glow as light is
transmitted through the air filled
frontal sinus to the forehead
•Ask the patient to open the mouth
wide and tilt he head back. (an
upper denture should first be
removed.)
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. A reddish glow
indicates a normal air filled
maxillary sinus
Absence of
glow on one or
both sides
suggests a
thickened
mucosa or
secretions in
the frontal
sinus, but it
may also result
from
developmental
absence of one
or both sinuses.

EYE
Inspection: eye brows:
distribution
Equal distribution in both
sides
Absent or abnormally
distribution
Eye lashes No infection, sty Present infection, sty,
dandruff
Eye lids No swelling, redness ,
lesions
Present swelling,
redness or lesions ,
ptosis
The eye for bulges
(proptosis)
No bulges Bulging, staring or
sunken eye
Conjunctiva for any
redness, paleness,
discharge, foreign body,
dryness or tear flowing
Dark pink in color, no
redness, paleness,
discharge, foreign body,
dryness or tear flowing; it
is just moist
Pale palpebral
conjunctiva indicate
anemia and redness
indicates conjunctivitis

EYE cont…
The sclera for any color
change, injury and
dilated blood vessels
White in color with few
small blood vessels
Yellow sclera
indicates jaundice
The cornea for color,
abrasions or white spots
Transparent , no
abrasions or white
spots
Cloudy
appearance ,
abrasions or
white spots
The pupils for size and
shape
Pupils are round and
uniform in size and
shape
Irregular size or
shape of the pupil
The pupils reaction to
light. Light a torch from
the side of the eye and
remove it. Observe how
pupil reacts
As the torch
approaches the ye,
pupils constricts and as
the torch is removed
the pupils dilate
Pupils remain
constricted even
after the torch is
removed

how_to_check_pupil_reflexes_response_cons
ensual_and_direct_reaction_nursing_clinical_
skills_aM0ipmW3ikc_240p.mp4

Examination of extraoccular muscles
• Hold the finger vertically at least 50 cm away from the
patient
• Cover the patient’s one eye
• Examination of extraoccular movements: 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

• The inability of the eye to gaze in any of the
six direction is an indication of weakness of
extra occular muscles
• A patient whose diplopia is maximal on
looking down and to the right has either a
weak right inferior rectus or a weak left
superior oblique muscle.

Cover test (squint test)
• Cover one eye and ask the patient to look at
the light of your pen torch
• Closely observe the uncovered eye for any
movements
• If it moves to take up fixation, that eye was
squinting
• Repeat the sequence for the other eye

cover_test_Wf8DGL7WE8U_360p.mp4

Convergence test (Accommodation)
• Ask the patient to follow the finger or pencil as
you move it in toward the bridge of the nose.
• Poor convergence in hyperthyroidism

near_point_convergence_RGY8otc2pMo_360
p.mp4

convergence_insufficiency_3IellKJnOJA_1080p
.mp4

Visual acuity test
• Snellen chart is used to test vision.
• Position the patient 20 feet (6 meter) from the
chart.
• Patient who uses glass other than reading glasses
should wear them
• Ask the patient to cover one eye and ask to read
the smallest line of the print possible

Sequence of examination
• Use a Snellen chart positioned at 6 meters (20 ft)
and dim the room lighting
• Cover one eye and ask the patient to read the
chart from the top 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

Snellen chart cont…
• If the patient cannot see the largest font,
reduce the test distance to 3 meters, then to 1
meter if necessary.
• If they still cannot see the largest font,
document instead whether they can count
fingers, see hand movement or just perceive
the difference between light and dark

Peripheral vision test
• Sit at about 1 meter away
• Ask the patient to cover one eye ask to look at the examiners
eye directly opposite
• Close your other eye
• Slowly bring a pencil or other small test being object from the
periphery into the field of vision from the 8 direction and ask
the patient to say” now” “dekhiyo” as soon as it appears
• Keep the test object equidistant between your eye and patient’s
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

• ..videosNeurology - Topic 31 -
Nystagmus.mp4

EAR
Inspection:
a. Location
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
The top of the
pinna does not meet
or cross the eye –
occiput line
b. Pinna: The pinna for
any lump or lesions
No lumps or lesion,
smooth rounded contour
lump or lesions
c. External auditory canals
for any ear discharge,
redness, mass, foreign
body or cerumen (A waxy
substance produced by
ceruminous gland in the
outer portion of the canal)
No discharge, redness,
mass or foreign body,
slight cerumen present
Clear blood or
yellow discharge,
redness, mass,
foreign body,
excessive cerumen
present

Ear cont..
d. (Pull ear up and
back for
adults)Tympanic
membrane: use
otoscope
No perforations,
lesions, bulging
Perforations,
lesions, bulging
Palpate the ears by
a. Pulling the upper
portion of the pinna
a little for
tenderness
b. Pressing the
mastoid area for any
tenderness
No tenderness
No tenderness
•Tenderness present
•Tenderness behind
the ear may be
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
• Normally the sound is heard longer through air
than through bone (AC>BC)

• Abnormal findings:
– If the sound is louder on the mastoid process, bone
conduction is better 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
sides
• Normally 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 finding:
– The noise is louder in an ear with conductive
deafness
– In unilateral sensorineural hearing loss, the sound
is better heard in the normal ear.

Weber Test Principles
• The inner ear is more sensitive to sound via air
conduction than bone conduction (in other words, air
conduction is better than bone conduction).
• In the presence of a purely unilateral conductive
hearing loss, there is a relative improvement in the
ability to hear a bone-conducted sound. This can be
explained by the following:
• Masking effect: The sound heard via the affected ear
has less environmental noise reaching the cochlea via
air conduction (for example, the environmental noise is
masked) as compared to the unaffected ear which
receives sounds from both bone conduction and air
conduction. Therefore, the affected ear is more
sensitive to bone-conducted sound.

• Occlusion effect: Most of the sound
transmitted via bone conduction travels
through to the cochlea. However, some of the
low-frequency sounds dissipate out of the
canal. A conductive hearing loss (in other
words, when an occlusion is present) will,
therefore, prevent external dissipation of these
frequencies and lead to increased cochlear
stimulation and increased loudness in the
affected ear.

Nose
Inspection
a. Location of nose Centrally located Deviated in location
b. The nostrils for
their size and flaring
Nostrils are uniform
in size and do not
flare
Asymmetrical in
size or flaring nostril
c. The nasal septum
for any polyps
(growths) using light
No polyp or
deviation
Presence of polyps
or deviation
d. Assess the nasal
canals with a torch
for redness,
discharge, foreign
bodies etc
Dark pink mucous
membrane, no
discharge or foreign
bodies
Red swollen mucosa
of acute rhinitis;
pale mucosa of
allergic rhinitis

Mouth and throat: inspection and
palpation
Inspection:
a. The lip for color,
moisture, lumps, cracks
or ulcers
Pink, moist and intact
skin, no bluish
discoloration, cracks
and ulcers
Lips bluish in color
cracks or ulcers
present
b. The mucous
membrane of the mouth
for the color, ulcer,
nodules and amount of
saliva
pink, moist mucous
membrane, no ulcer,
nodules
Inflammation,
swelling, redness
or bleeding present
c. The gums for
inflammation, swelling,
redness or bleeding
Pink, no
inflammation,
swelling, redness or
bleeding
Inflammation,
swelling, redness
or bleeding present

d. The teeth for the
color, caries and
missing tooth
White teeth, no caries
and missing teeth
Brown teeth,
presence of caries
or missing teeth
e. The tongue for
symmetry, color and
papillae
Symmetry, pink,
moist, papillae and
midline fissure
present
Asymmetrical, red,
pale, dry papillae
or fissure absent
f. The throat and note
the color and size of
the tonsils
Pink throat and a
small tonsils
Red swollen and
yellow discharge
on the tonsils
g. The swallowing
difficulty by asking
the patient to swallow
No difficulty in
swallowing
Difficulty in
swallowing

Palpate:
a. The gums on both sides
with fore fingers of the right
hand and check for swelling
and tenderness (use gloves if
available)
No swelling, no
tenderness
Swelling and
tenderness present
b. The teeth by moving them
with the fore fingers of the
right hand for any pain or
loose teeth
No toothache, no
loose tooth
Toothache or loose
teeth present
•Smell:
•The patient’s breath and note
any foul odor or alcohol smell
in the breath
No foul odor nor
smell of alcohol
Breath odor of
alcohol, acetone in
diabetes mellitus,
pulmonary infection,
uremia etc

Lymph nodes
Inspection:
Redness or
enlargement of
lymph nodes
Lymph nodes not
visible, no
redness
Enlargement and redness of
lymph nodes
Palpation:
enlargement and
tenderness
Lymph nodes are
not palpable and
tenderness
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: use inspection and palpation
Inspect
•The neck by asking the
patient to sit straight.
Note the position often
head and neck
•Observe masses and
scars of the neck
•No tilting of the
head
•No masses, scars
•Tilting of the head
•A scar of past thyroid
surgery may be the clue
to the unsuspected
hypothyroidism
•Enlargement of the
thyroid gland
•Thyroid gland not
visible and enlarged
•Enlarged thyroid gland
•For the ability to move
neck up and down and
from side to side. Note
any stiffness or
tenderness
•Full and smooth
range of movement,
no stiffness or
tenderness
•No swelling or lump
•Swelling, tenderness
and decreased range of
motion suggests arthritis
•Swelling or lump
present

Palpation
•The back of the
neck along the
spine and back of
the head.
•Check for the
muscle tightening,
tenderness, lump
etc
•Palpate thyroid
gland
•No tightness of
the neck muscles
•No tenderness
along the spine
•Thyroid gland is
palpable in 50 %
and 25% of men
normally
•Muscle
tightening,
tenderness along
the spine, lump
along the spine
•Nodules,
irregular mass
present

Chest and lungs: use I,P,P,A
Inspect
a. the chest for
Size and shape:
note the
anterioposterior and
lateral diameters of
the chest
Lateral diameter (side
to side) is wider than
anterioposterior (front
to back) diameter
•Barrel shaped chest
(increase antero posterior
diameter) 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
b. The symmetry:
note the location of
sternum
Symmetrical shape,
sternum is located at
the midline
•Sternum is displaced

c. The intercostal spaces
whether they move in
(retract) when the patient
breathes in
No intercostals
retraction
Retraction at the
intercostal spaces
d. The cough: if the patient
has cough, ask him to
cough up the sputum and
check the amount and color
of sputum
No cough, no
sputum
Brownish grey,
yellow, grey, bloody
or frothy sputum
Palpation
Check for tenderness,
lumps, depression along
the ribs
No tenderness,
lump or
depression along
the ribs
Tenderness of the
chest, lump or
depression along
the ribs present

Assessment of 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.
Slight displacement to the right is common in
healthy people.
• Measure the distance between suprasternal notch
and cricoid cartilage, normally 3 – 4 finger
breadths, any less suggests lung hyperinflation.

– Shift of the upper mediastinum causes tracheal
deviation

Chest expansion
• Stand behind the patient and assess expansion of
the upper lobes by watching the clavicles during
tidal breathing
• Assess expansion of the lower lobes by placing
your hands firmly on the 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 finding:
– Both sides of the thorax should expand equally
during normal breathing and maximal inspiration
– Reduced expansion on one side indicates
abnormality on that side
– For e.g. pleural effusion, lung or lobar collapse,
pneumothorax

Tactile fremitus

Percussion
• Put the middle finger of your non-dominant
hand firmly to an intercostal space, parallel to
the ribs, and drum (strike) the middle phalanx
with the flexed tip of your dominant index or
middle finger.
• Percuss in sequence (L shaped), comparing
areas on the right with corresponding areas on
the left before moving to the next level

Percussion
• Posteriorly, the scapular and spinal muscles
obstruct percussion, so position the patient
sitting forwards with their arms folded in front
to move the scapulae laterally.
• Compare positions the same distance from the
midline on right and left

Lung percussion sound
Percussion sound Remark
Resonant Normal lung
Hyper resonant Pneumothorax
Dull Pulmonary consolidation
Severe pulmonary fibrosis
Pleural effusion
Hemothorx

Auscultation
•Auscultation of
breath sound
•To compare the
duration of inspiration
and expiration
•Check for any
abnormal sounds like
rales, (fine crackling
sounds.)
•Ronchi (loud bubbly
sounds) and wheezing
•Inspiration
longer than
expiration
•No rales,
ronchi and
wheezing
sounds
•Prolonged
expiration
•Rales, ronchi,
wheezing
sounds, pleural
rub, crepitations
present

Auscultation
• Ask the patient to be relaxed and breath deeply
through the mouth
• Do not ask the patient to breath deeply for
prolonged periods. This may cause giddiness and
tetany
• Auscultate each side alternately, comparing
findings over a large number of equivalent
positions to ensure that you do not miss localized
abnormalities

Auscultation cont…
• Listen
– Anteriorly from above the clavicle down to the
sixth rib
– Laterally from the axilla to the eight rib
– Posteriorly down to the level of 11th rib
• Assess the quality and amplitude of breath
sounds
• Identify the inspiration and expiration time

• Auscultate breath sound:
• 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

lung_sounds_normal_bronchial_bronchovesic
ular_vesicular_breath_respiratory_sounds_JF
WMJGtmG5E_1080p.mp4

Abnormal sounds
lung_sounds_respiratory_auscultation_sound
s_2NvBk61ngDY_1080p.mp4

Heart
Inspection
Enlargement of neck
(jugular) vein
No
enlargement
Enlargement
Scar marks History of
surgery

Palpation
• Apex beat at 5th intercoastal spaces or just
below the nipple
• Palpate for thrill at the apex and both sides of
the sternum using the flat of your fingers

Auscultation of heart sounds
• 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

heart_sounds_and_heart_murmurs_animatio
n_dBwr2GZCmQM_360p.mp4

Auscultation of heart rate:
• Count the heart rate, compare the radial pulse
to detect skipped beat by using stethoscope

• Normal findings:
– 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 finding:
– Decreased or inaudible heart sounds irregular or
missed heart beats
– Heart rate less than 60 or more than 80 b/m.
– Murmur sound present

Female breast
Inspection
•Size and shape of
the breast.
•Observe nipples
point to the same
direction
•Look for any
swelling and
dimpling or
retraction of breast
•The nipple for
cracks and
discharge
•Breast and nipples are
uniform in size and shape
and nipples point to the
same direction
•It is the normal for one
beast to be slightly larger
than the other
•No swelling, dimpling and
retraction of breast
•No enlargement of veins
•No cracks, milky discharge
in pregnant or breastfeeding
women
•Irregular in
shapes, redness
over the breast,
swelling and
retraction
•Dimpling breast
suggests an
underlying cancer
•Cracks, yellow or
bloody discharge

Palpate both the
breasts in a
circular motion
and check for any
mass, swelling
and tenderness
Soft, non tender
and often ridge of
tissue felt at the
bottom of breast
Hard, irregular,
poorly
circumscribed
suggest cancer
Male breast
A firm disc of glandular enlargement in a male is called
gynecomastia

Abdomen
Inspection
For the shape, scars,
swelling and distended
blood vessels
Rounded or flat
and uniform
shape, no scar,
swelling and
visible blood
vessels in
abdomen
Irregular in shape
Abdominal scars
present indicating
previous injury or
surgery. Swelling of
abdomen and
distended blood
vessles

Auscultation
For bowel sounds,
listen carefully in all
areas 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 quadrant
for 5 min
Bowel sound
present in all areas
(bowel sounds are
produced in every
5 – 15 seconds)
Clicks and gurgling
sounds
•High pitched
tinkling sounds,
absence of bowel
sound (no bowel
sound heard for 5
minutes)
•Loud rushing
sound

Examination Normal
data
Abnormal
data
Percussion
•Keep the patient in supine position.
•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).
•Shifting dullness:
Then turn the patient on his side and
pause for 10 seconds. Again percuss all
the Side areas. Note if there is shifting
dullness when the patient is moved.
Shifting dullness is a sign of fluid in
abdomen.
Sacttered
area of
tympany
and
dullness
Absence of
tympany

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.

Fluid Thrill cont.…
• Then 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.

Examination Normal
data
Abnormal
data
Palpation
Place the patient in the supine position and
ask him to relax his abdomen
Palpate the abdomen in all four quadrants
fell for any masses or tenderness
Ask the patient to breath in deeply and
gently palpate
The liver: place the left hand on the back
beneath the patients 11th and 12th rib and
apply upward pressure to push the liver
forward towards the examining right hand .
Place the palmer surface of the right hand
parallel to the coastal margin.

•Ask the patient to
take a deep breath and
as the liver sliding
over the fingers.
•Note any enlargement
or tenderness.
•If enlarged, estimate
the amount of
enlargement beyond
the right coastal
margin.
Express it in
centimeters
No abdominal mass
and tenderness
Liver is not usually
palpable but in thin
people it may be
palpable immediately
below he coastal
margin as a smooth
structure wit ha
regular contour and a
firm, sharp edge
Liver palpable as
soft or hard edge
or irregular in
contour

data
The spleen
Keep the patient in right lateral
position. Place the left hand on
the patient’s back under the left
rib cage.
Apply upward pressure in the
pressure in the left upper
quadrant with the right hand
fingers moving towards the
anterior axillary line and
beneath the coastal margin. Feel
for the enlargement or
tenderness of the spleen
Spleen is not
palpable. No
enlargement
and tenderness
on palpation
Spleen enlarge
and tender

Examination Normal
data
Abnormal
data
Kidneys:
Keep the patient in the supine
position. Place the left hand on
the patient’s back between the
lowest rib
Ask the patient to take deep
breaths.
Press firmly with the right hand
and try to feel the kidney. Feel on
the left side too.
Note the enlargement or
tenderness on kidneys
Kidneys are
not palpable
and tender
Kidneys
enlarged and
tender

Anus
data
Use inspection
The anus for any irritation,
crack, fissures or enlarged
vessels
No irritation,
fissure, cracks
or enlarged
blood vessels in
the anus
Presence of anal
irritation, anal
fissure and
enlarged anal
blood vessels
Male genitals
Use inspection, palpation
Inspection
•The penis for any sores or
lumps
•The scrotum for any redness,
swelling or any lesions
No sore, lump
No swelling,
redness or
lesions
Presence of sore
or lumps
Swelling, redness
or lesions of
scrotum

Palpation
•Palpate testes for
Enlargement or
tenderness of
scrotum
No enlargement,
tenderness or
scrotum.
Testes are equal in
size, no tenderness
Enlargement or
tenderness of
scrotum, one testis is
larger than the other

data
Female Genitals
Inspection
The labia for color and
look for redness or
swelling of the labia.
Check the urethral
orifice for redness or
discharge
Look for any discharge
or bleeding from the
vagina
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)
Red or swollen
labia
Redness or
discharge at
urethra
Unusual
discharge and
bleeding (except
during
menstruation)

Musculoskeletal system
data
and movement
Inspection:
a. The muscles and joints:
• Ask the patient to stand.
• Inspect his neck, shoulder,
arms, hands, hips, knees,
legs, ankle and feet.
• Note any bone or joint
deformity, joint redness,
swelling or muscle
wasting
•No bone or
joint
deformity, no
redness,
swelling of
joints, no
muscle
wasting
•Presence of
bone
deformity,
joint
deformity,
joint redness
or swelling,
muscle
wasting

Palpation
•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
No joint
swelling or
tenderness
Normal
temperature
•Joints swelling
suggests
rheumatoid
arthritis
•Increased
temperature
over a joint

data
•The joint movement.
• Ask the patient to move
his neck, shoulder,
elbows, wrists
Compare one side with
the other side.
•Able to move
joints freely.
•No sign of pain
while moving
joints
•Limited
movement of
the joint.
•Signs of
pain when
moving the
joint.

•Ask the patient to
move his Fingers,
hip, knees ankles
and toes one by
one in all possible
directions
•Able to move
joints freely.
•No sign of pain
while moving
joints
•Conditions that
impair range of
motion include
arthritis,
inflammation of the
tendon sheaths and
fibrosis in palmer
fascia .

•Make a fist with
each hand, thumb
across the knuckles
and then extend
and spread the
fingers
•Inspect the
patient’s spine.
Note its placement
and curvature
•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
form the neck and
gradually curving
inward at the waist
•Lateral deviation
of spine, increased
curvature of spine.
•Increased curvature
of spine or
flattening of curves
of the spine.
Decreased spinal
mobility in
osteoarthritis.

Examination Normal
data
Abnormal data
•Range of motion at
knees and hips.

Stretch test: Sciatic nerve(L4-5,S1-3)

Assess the
orientation:
By asking the
patient about the
current time,
place and
pointing out to a
person and
asking “ who is
he/ she?”
Patient says the
correct current
time, place of
stay and the
person pointed at
Patient cannot
say the correct
current time,
place of stay and
the person
pointed at

Nervous system
data
Muscle strength: Equal strength in
both hands and
feet. No muscular
weakness
Muscular
weakness in one
or both hands and
feet
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
Feels light brush of
the cotton equally
on both sides of his
body
Loss of sensation
to light brush
Coordination of movement: ask the
patient to button his shirt or to tie
his shoes
Coordinated
movements
Uncoordinated
movement

Assessment of power
Score Remarks
0 No muscle contraction visible
1 Flicker of contraction but no movement
2 Joint movement when the effect of gravity
eliminated
3 Movement against the gravity but not
against examiners resistance
4 Movement against resistance but weaker
than normal
5 Normal power

Reflex
• In a normal person, when a muscle tendon is
tapped briskly, the muscle immediately
contracts due to nerves that innervates the
muscle.

Babinski reflex (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

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 .

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 .

Knee
• 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

Achilles tendon
• The ankle reflex is elicited by holding the
relaxed foot with one hand and striking the
achilles tendon with the hammer and noting
plantar flexion.
• Compare to the other foot

deep_tendon_reflex_examination_for_nursing
_head_to_toe_assessment_of_neuro_system
_eqOpNQH09pA_1080p.mp4

Physical examination, Fundamentals of Nursing

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