1

Physical Exam Guide

Patient sitting, face to face

*Upper extremities—Assess and Palpate

Skin—
Color- ;Temp.- use back of hand; Moisture- Texture- Turgor
Nails—
Shape and Contour; consistency; color
Radial pulses—Bilat. simultaneously
Shoulders- assess and palpate bilat by starting at clavicle feel bones, pockets, and
muscles.
ROM- Cup 1 hand over each shoulder during movement for crepitus.
Pt Arms at side and elbows, extended , move both arms forward and up in wide
vertical arcs and then back as far as can; rotate arms internally behind back
(stand at ease position) raising them as high toward scapula as possible; Arms
extended at sides, abduct until palms touch, then bring one arm at a time back
down and as far across body as possible w/ out bending elbow; Place both
hands behind head (arresting position).
Strength- Pt shrugs shoulders forward and backward against resistance.
Elbows- assess and palpate using gripping motion from above elbow to below it.
ROM- arm on table with thumb up, w/out lifting arm place palm on table and then
knuckles on table.
Strength- Pt. extend and flex once and then again while I hold pt wrist and under
elbow providing resistance and feeling for crepitus.
Wrist- Palpate each joint in wrist/hands (hold pt hand w/ my two hands w/ thumbs
on back of hand).
ROM- Pt bends hand up & down at wrist, bend fingers up & down while straight,
w/ hand on table, turn wrist toward thumb and then toward pinky; spread fingers
apart, make a fist; touch thumb to each finger and to the base of little finger.
Strength- Pt. flexes and extends wrist, hold pt arm w/ palm up on table at the
forarm and other hand on pt’s hand. Hand grips bilaterally.
*deep tendon reflexes (biceps, triceps, brachioradialis) bilat- Bicept- support Pt
forearm on mine, gripping above Pt elbow with thumb on biceps tendon and strike
a blow on my thumb with REFLEX HAMMER. Triceps- Hold bicep as Pt lets
arm dangle, strike triceps tendon just above the elbow. Brachioradialis- Hold Pt
thumbs to suspend forearms relaxed, strike forearm directly about 2 to 3 cm above
the radial styloid process.
 2

Head and Face

inspect hair and scalp- color, texture, distribution, lesions
palpate scalp- size and shape, temporal arteries- bilat.
*palp temporal-masseter muscles- ask pt. to clench teeth after opening and closing
(CN V) any tenderness?
, facial sensation- w/ pt. eyes closed, lightly touch pt. forehead, cheeks, and chin
with COTTON
*facial expressions (CN VII)- pt. smiles, frowns, closes eyes tightly while I try to
open them, raise eyebrows, show teeth, puff cheeks while I press them in.
Sensory- taste test w/ SUGAR AND SALT with pt. eyes closed.
Eyes
inspect lids, conjunctiva, & sclera- use thumbs to pull down lower lids. Lacrimal
apparatus- Pt. looks down, slide outer part of upper eyelid up along bony orbit to
check for redness/swelling. Press into the inside lower orbit rim.
*assess visual acuity and visual fields by confrontation (CN II)- Pt. 2 ft. from me
at eye-to-eye level. Cover 1 eye of pt and mine on same side, both looking
straight ahead, bring PEN in from above, below, sides, behind pt. ear for
peripheral vision test. Pt. says “now” when pen he sees pen.
*EOM’s (CN’s III, IV, VI)- Pupil size, regularity, equality, direct and consensual
light reaction
pupilllary light reflex- Darken room, pt. gazes into distance, advance PEN
LIGHT in from side and note response (direct and consensual).
*corneal reflex (CN V)- Remove contacts, Pt looking forward, bring WISP OF
COTTON in from side and lightly touch cornea but not conjunctiva. Bilateral
blinking
*funduscopic exam- Pt. looks at mark on wall even if I block view.
OPHTHALMOSCOPE in right hand to right eye to examine pt. right eye. Other
hand on forehead and thumb anchors upper-lid. Start 10in. away at 15 degree
lateral position. Note Red Reflex. Move closer to eye while advancing lens to +6
and note opacities. W/ heads almost touching, adjust diopter so fundus is in focus
(N=0). Red lenses for nearsighted and black for farsighted. Look for Optic Disk
on nasal side of retina; Retinal vessels, General background- N= light red to dark
brown-red; Macula- N=1DD in size, 2DD temporal to disk, darker than rest of
fundus.
 3

Ears
*inspect & palpate external auricle- size/shape, swelling/redness/discharge, any
tenderness?
*Inspect canals & TM’s- use the largest speculum for OTOSCOPE that will fit.
Tilt pt head toward shoulder opposite me. Pull pinna up/back, keep traction until
scope removed. Hold upside down while bracing hand dorsa on pt cheek. Look
around at external canal for red/swell/foreign objects/leakage. Tympanic
membrane- N= shiny/translucent, cone shaped light reflex in anteroinferior
quadrant. Eardrum- pt swallows while holding nose (flutters), look for
perforations/scarring.
*assess acuity (voice test) (CN VIII)- rapidly push in and out on opposite tragus
while pt closes eyes. From 1ft away, have pt repeat after I whisper Tuesday,
Armchair, Baseball, Fourteen. Weber Test- strike tuning fork on back of my hand,
place on middle of pt skull, “Is it louder in one ear than other?” Rinne Test- place
on mastoid process (behind ear), pt. signals when sound goes away, immediately
place tines near ear canal, pt again signals when sound goes away. Time bone and
air conduction times.
Nose
palpate sinuses- press thumbs over frontal sinuses below eyebrows, over
Maxillary sinuses below cheekbones. Any tenderness?
assess patency of nares- block off 1 side at time while pt. inhales through nose.
*assess smell (CN I)- occlude one nostril, pt eyes closed, pt smells
TOOTHPASTE one side/ ORANGE other side.
inspect membranes/turbinates- Lift up tip of nose; use short, WIDE-TIPPED
SPECULUM to otoscope inserted into nose w/out pressing on septum; look w/ pt
head erect and head tilted back. Look at mucosa, septum, turbinates.
Mouth
inspect & palpate lips, mucosa, ducts, gums, teeth, roof & floor of mouth- wear
gloves, use penlight
Pt bites down, note alignment of upper/lower jaw and margins at teeth.
inspect and palpate tongue- Pt touches roof of mouth w/ tongue, assess ventral
surface; hold tongue w/ COTTON GAUZE while swinging it out and to each
side. Feel U-shape under tongue w/ one hand and other hand holding jaw. DON’T
BITE ME!
*inspect palates, uvula, tonsils (CN IX, X)- w/ penlight, uvula- look for
movement while pt says “ahh”, tonsils- use TONGUE BLADE to press
down on side of back of tongue; touch posterior wall to elicit gag reflex.
DON’T PUKE ON ME!
*hypoglossal (stick out tongue) (CN XII)- Pt sticks out tongue, assess for tremor,
loss of movement, deviation to 1 side. Pt. says “light, tight, dynamite”.
 4

Neck
*Palpate carotid arteries- one at a time, using hand on same side; listen for carotid
bruit w/ STETHOSCOPE bell in 3 spaces. Lymph nodes- use gentle, circular
motion of finger pads to palpate lymph nodes using both hands. 1. In front of
tragus, 2. Behind ear, 3. Just below 2, 4. under chin, one hand palpate w/ other
positioning head, 5. under angle of jaw, 6. move up jaw line to base of ear, 7. top
of neck, below jaw line, 8. laterally to trachea, tip head toward examined side to
relax muscles, 9. posterior to 8, 10. midclavicular, above clavicle, hunch
shoulders and elbows forward.
ROM- Chin to chest, Turn R&L, Ear to shoulder, extend backward.
*spinal access/sterno mastoid (CN XI) neck strength/shoulder shrug- Pt rotates
chin forcefully against chin resistance. Pt shrugs shoulders against
resistance.
note position of trachea- check for shift, index fingers on trachea in sternal notch,
slip fingers off to each side. N=symmetric.
Move behind patient
*palpate thyroid gland, swallow (CN’s IX & X)- Pt sip and swallow H2O while
inspecting. Pt head forward and slightly to right. Displace trachea to right w/ left hand
and palpate w/ right hand as pt swallows (choke-hold position).

Patient sitting, nurse behind:

Back/Lungs
Inspect and palpate skin, shape, spine, muscles- Use fingers to gently palpate.
Barrel Chest?,?, Neck and Trapezius muscles. Tripod position?
spinal tenderness/CVAT- Place 1 hand over 12th rib at CVA, thump flat hand w/
ulnar edge of other hand, Any pain?
tactile fremitus- using ball of fingers, feel for vibrations in auscultory pattern
while pt says “99”.
respiratory excursion- Symmetrical features/expansion upon inhaling (1 hand
each side of spine at T-10 area, push thumbs together pinching skin, watch for =
thumb movement)
*percussion- Start at apices, percuss across top of shoulders, then in interspaces
from side to side
diaphragmatic descent- Map-out lower lung border. Pt exhales and holds it, bilat.
percuss down scapular line until resonance heard and then down to where dullness
is heard (level of diaphram), mark that spot. Pt. inhales and holds it. Bilat. percuss
down from mark until dullness heard again. Mark that spot. Measure distance b/n
spots with RULER.
*auscultation (vocal fremitus)- Use diaphragm of steth. Pressed firmly on back. 1
full resp. in each location. Side-to-side comparison, including axilla thru T8 on
right side. Vocal resonance- Pt. says “99” (Bronchophony), “ee-ee-ee-ee”
(Egophany- EA change?), whispers “1, 2, 3” (Whispered Pectoriloquy)
 5

Lungs and Chest

Inspect skin, shape, sternum, muscles, palpate for tenderness
tactile fremitus- “99” starting in apices
Percussion- start in supraclavicular areas, then the interspaces to below pectorals
(6th rib)
*auscultation bilaterally- follow same pattern as percussion (5 areas bilat); Pt
exhales and holds, leaning slightly forward, listen w/ diaphragm to Aortic and
Pulmonic areas for murmur.

Pt lying down, nurse on right

Cardiovascular
chest wall movements- Palpate = chest rise- hands below pectorals w/ thumbs
pointing toward xiphoid process
check for JVD- hold vertical ruler on sternal angle, use horizontal ruler like a T-
square and adjust to level of pulsation of internal jugular. (2 RULERS)
locate PMI- Pt exhales and holds it, feel with 1 finger for PMI
*auscultate bell/diaphragm (aortic, pulmonic, tricuspid, & mitral)- feel carotid
while listening for S1. After auscult. supine, roll Pt. onto left side and listen w/
Bell at apex (mitral).
Abdomen
Inspect size, shape, scars, symmetry, turgor
*bowel sounds/bruits- use diaphragm, note character (normal, hypo/hyperactive,
borborygmus), begin in RLQ. Vascular sounds- over aorta w/ firmer pressure;
renal; femoral (usually no sound)
*percuss all quads, liver and spleen- Tympany prevalent. Liver span- Right
midclavicular line, begin with lung resonance and work down until dullness.
Mark spot (usually at 5th intercostal), find abdominal tympany in midclavicular
line and work up until dullness. Mark spot and measure distance b/n marks. N=6-
12cm. Splenic dullness- percuss behind left midaxillary line from 9th to 11th
intercostal. Percuss lowest interspace in Left anterior axillary line. Tympany
should result. Pt. takes a deep breath and tympany should remain.
*light/deep palpation – liver, kidneys, spleen, aorta- Size, location, consistency. Pt
knees bent, my hands low/parallel w/ abdomen. Pt breathing slowly. My voice
low/soothing. Light palpation- 1st 4 fingers close together, depress skin 1cm
making gentle rotary motion. Lift fingers (don’t drag) move clockwise over
abdomen. Palpate tender areas last! Deep palpation- depress 2 to 3 inches
clockwise. N=tenderness over Sigmoid colon, not anywhere else. Liver palpation-
RUQ, place left hand under pt’s back at 11/12th rib level and lift for support. Right
hand on RUQ w/ fingers parallel w/ midline. Push deeply down and under right
costal margin. Pt takes deep breath, edge of liver should bump fingertips (firm,
regular ridge). Right kidney- press hands together like a clam, pressing harder
than liver palp. while Pt takes deep breath. Spleen palpation- reach left hand over
abdomen behind pt’s left side at 11/12th ribs, lift for support. Right hand presses
obliquely toward left axilla inferior to costal margin in LUQ. N=nothing firm.
Left kidney- same as spleen but right hand fingers press perpendicular to midline
 6

into flank area N= not palpable. Aorta Palpation- use opposing thumb and finger,
upper quadrant, left of midline.
femoral pulses and inguinal nodes- Femoral Artery Palpation- Just below inguinal
ligament. Pt. bends knees to side (frog like). Press firmly then release, noting
pulse tap on fingers bilaterally. Inguinal Lymph Nodes- Inner area of anterior
thigh in inguinal sector.
Lower Extremities
*inspects for color, hair distribution, deformity, lesions b/n toes, edema- over
tibia, pulses (popliteal- Pt leg extended but relaxed, anchor thumbs on
knee and curl fingers under, press fingers forward, often felt lateral to
medial tendon; Dorsalis Pedis- light touch on top of foot b/n 1st 2 tendons;
Posterior Tibial- medial malleolus (inside anklebone), pt. dorsiflex foot)
heel-shin- Pt places heel on opposite knee and runs down length of shin to ankle
bilaterally.
*hips/knees/ankles/feet ROM/palpate joints- stable w/out crepitus. Hips-
(Bilaterally) ROM-Pt raise each leg w/ knee extended then against resistance. Pt.
bend knees to chest w/ other leg straight (resistance applied later), flex knee/hip to
90 degrees while I hold thigh and ankle to stabilize, swing foot inward/outward.
Pt abducts/adducts leg with knee extended then against resistance. Knees-
(Bilaterally) Move hand down leg in grasping fashion from 10cm above patella to
top of patella. Palpate bottom of patella at tibiofemoral joint while Pt. flexes and
extends knee. Strength- Pt maintains knee flexion while I pull to straighten at
heel, Pt extends knee against resistance at ankle. Ankles and Foot- Support ankle
by grasping w/ fingers while palpating w/ thumbs. Palpate joints in feet and toes.
ROM- Pt points toes toward floor/nose; turn soles out/in while I stabilize ankle
and heel (assesses subtalar joint); flex and straighten toes. Strength- maintain
dorsiflexion and plantar flexion against resistance.
*deep tendon reflexes (patella, achillies) bilat- Quadriceps- Pt lower leg dangles,
strike tendon just below patella. Achilles- Pt. knee flexed and hip externally
rotated, hold foot in dorsiflexion while striking achilles tendon directly.

Patient sitting, face to face:

Neuro-Musculoskeletal
stereognosis/graphesthesia- Stereognosis- Pt eyes closed, place KEY in hand and
ask Pt to identify. Graphesthesia- Trace the number 8 onto Pt’s palm w/ Pt eyes
closed.
rapid alternating movements (hands, fingers)- Pt pat knees w/ palms and then with
backs of hands progressively faster. Pt. touches thumb to each finger on same
hand starting w/ index finger, then reverse direction.
finger to nose- Pt. closes eyes and stretches out arms. Pt touches tip of nose w/
index fingers alternating hands progressively faster.
sensation--soft/sharp/dull/vibratory- Compare on symmetric parts. Pt. eyes closed
during each test. Pain- pinprick w/ half of TONGUE BLADE tip and then round
edge for dull. Pt. says sharp or dull. Soft- wisp of cotton to skin at arms, forearms,
hands, chest, thighs, and legs. Pt. says “now” when he feels it. Vibratory- use
 7

tuning fork over bony surface of fingers and big toe. Pt states when vibration
starts and stops.

Patient standing:
ROM including spine/touch toes- Pt. touches toes bending forward w/ legs
straight, bends sideways, backwards, twist at shoulders from one side to other.
gait, hop on one foot- Pt walks 20 feet and returns to starting point.
Rhomberg/pronator drift- Pt stands w/ feet together, hands at sides, Pt closes eyes
and stands there for 20 seconds. Pt hops in place one leg at a time.