Procedure: PHYSICAL ASSESSMENT

Desired Learning Outcomes:

1. Identify the purposes of the physical examination.
2. Explain the four techniques used in physical examination; inspection, palpation,
percussion, and auscultation
3. Identify expected findings during health assessment
4. Demonstrate the steps in performing selected examination procedures such as
assessing appearance and mental status; assessing skin; assessing hair; assessing
nails; assessing the skull and face; assessing the eye structure and visual acuity;
assessing the ears and hearing; assessing the nose and sinuses; assessing the
mouth and oropharynx; assessing the neck, thorax and lungs, heart and central
vessels, peripheral vascular system, assessing breasts and axillae, abdomen,
musculoskeletal system, neurologic system, genitals and inguinal area and anus.

LEARNING CONTENT

Physical Assessment Tools, Instruments and Supplies

The physician primarily works with the physical assessment tools; however, the medical
assistant must become familiar with their uses to assist the physician during a physical
assessment. The medical assistant can also be responsible for disinfecting and sanitizing the
instruments and preparing them for the physician before the next physical examination. The
physical assessment includes an audioscope, examination light, laryngeal mirror, nasal speculum,
otoscope, ophthalmoscope, penlight, percussion hammer, sphygmomanometer, stethoscope,
thermometer, and tuning fork.

Audioscope – tool used to screen patients for hearing loss. The audioscope is placed in the
patient’s ear and makes a serious of tones which the patient can respond to.

Examination Light – the medical assistant must make sure that all lights in the physical
examination room are functioning properly and directed appropriately for the physician to exam
the patient’s body.

Laryngeal Mirror – tool used to exam the larynx and other areas of the throat. The laryngeal
mirror reflects the inside of the mouth and throat for the physical examination. It may be used to
visualize the throat for the application of anesthesia or to remove tissue from the mouth.

Nasal Speculum – tool inserted into the nostril to assist the physician with the visual inspection
of the lining of the nose, nasal membranes and septum.
Otoscope – allows the physician to view the ear canal and tympanic membrane.  The otoscope
has a magnifying lens, light and cone-shaped insert to examine the inner ear.

Ophthalmoscope – tool used to examine the interior structures of the eye. The ophthalmoscope
has a light, magnifying lens and opening for the physician to view the eye.

Penlight – provides additional light for the physician to examine a specific area of the patient’s
body. The penlight is typically used to examine the eyes, nose and throat.

Percussion Hammer – tool used to test neurologic reflexes. The head of the instrument is used
to test reflexes by striking the tendons of the ankle, knee, wrist and elbow.

Sphygmomanometer – physical examination tool used to measure a patient’s blood pressure.

The sphygmomanometer is composed of an inflatable rubber cuff, a bulb that inflates and
releases pressure from the cuff, and use of a stethoscope to listen to arterial blood flow in the
patient.

Stethoscope – tool used for listening to body sounds including the sounds of the heart, lungs and
intestines. It is also used while taking blood pressure.

Thermometer – tool used to measure a patient’s body temperature. The thermometer can be
inserted in the mouth under the tongue, under the armpit or into the rectum.

Tuning Fork – tool used to test a patient’s hearing. The physician strikes the prongs causing
them to vibrate and produce a humming sound. Then the prongs are placed next to the patient’s
skull, near the ear, with the patient describing what they heard. The physician may order
additional tests depending on the results of this hearing test.

Physical Assessment Tools & Supplies

Additional Supplies are needed for a general physical examination. They include cotton balls,
cotton-tipped applicators, disposable needles, disposable syringes, gauze, dressings and
bandages, gloves, paper tissues, specimen containers, and tongue depressors.

Cotton Balls – used to stop bleeding from minor punctures after injections or while drawing a
patient’s blood.

Cotton-Tipped Applicators – used to collect or treat a wound and to apply topical medication
to the patient during a physical examination.

Disposable Needles – used to inject medicine, anesthetic or other fluids during a physical
examination. Also used to extract blood from the patient for laboratory testing.
Disposable Syringes – added to a needle to extract blood or inject fluids during a physical
examination.

Gauze, Dressings and Bandages – used to cover up open wounds. Non-sterile pads can be used
to cushion, clean or absorb areas that are at less risk of infection.

Gloves – worn by the medical assistant and physician to keep bodily fluids from being absorbed
into the skin.

Paper Tissue – helps keep exam chairs, tables and other areas hygienic. The paper tissue is
replaced between each examination by the medical assistant.

Specimen Containers – used to hold blood, urine and other bodily fluids during an examination
for later laboratory testing.

Tongue Depressors – used to depress the tongue of a patient to examine the mouth and throat
during a physical examination.

Safety considerations:

 Perform hand hygiene.

 Check room for contact precautions.
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g., name and date of birth).
 Explain process to patient.
 Be organized and systematic in your assessment.
 Use appropriate listening and questioning skills
 Listen and attend to patient cues.
 Ensure patient’s privacy and dignity.
  Assess ABCCS (airway, breathing, circulation, consciousness,
safety)/suction/oxygen/safety.
 Apply principles of asepsis and safety.
 Check vital signs.
GENERAL APPEARANCE
1. General appearance:
 - Affect/behaviour/anxiety
 - Level of hygiene
 - Body position
 - Patient mobility
 -Speech pattern and articulation
SKIN, HAIR, AND NAILS:
Inspect for lesions, bruising, and rashes.
Palpate skin for temperature, moisture, and
texture.
Inspect for pressure areas.
Inspect skin for edema.
Inspect scalp for lesions and hair and scalp for
presence of lice and/or nits.
 Inspect nails for consistency, colour,
and capillary refill.
HAIR AND NAILS
 Inspect the evenness of growth over
the scalp
 Inspect hair thickness
 Inspect hair texture and oiliness
 Note presence of infections or
Rationale
Alterations may reflect neurologic
impairment, oral injury or
impairment, improperly fitting
dentures, differences in dialect or
language, or potential mental illness.
Unusual findings should be followed
up with a focused neurological system
assessment.
Check for and follow up on the
presence of lesions, bruising, and
rashes.Variations in skin temperature,
texture, and perspiration or
dehydration may indicate underlying
conditions.
Redness of the skin at pressure areas
such as heels, elbows, buttocks, and
hips indicates the need to reassess
patient’s need for position changes.
Unilateral edema may indicate a local
or peripheral cause, whereas bilateral-
pitting edema usually indicates
cardiac or kidney failure.
Check hair for the presence of lice
and/or nits (eggs), which are oval in
shape and adhere to the hair shaft.
 infestations
 Inspect amount of body hair To determine its curvature and angle
 Inspect fingernail plate
 Inspect texture and nailbed color
 Perform blanch test
SKULL AND FACE
 Inspect the skull for size, shape and May indicate excessive growth
symmetry, facial features hormone or increased bone thickness
 Note symmetry of facial movements,
ask the client to elevate the eyebrows, Facial asymmetry may indicate
frown or lower the eyebrows, puff the neurological impairment or
cheeks and smile and show the teeth injury. Unusual findings should be
followed up with a focused
neurological system assessment.
EYES AND VISION
 Inspect eyes for drainage Drainage may indicate infection,
 Inspect the eyelashes for evenness of allergy or injury.
distribution and direction of curl
 Inspect eyes for pupillary reaction to Slow pupillary reaction to light or
light unequal reactions bilaterally may
 Inspect the pupils for color, shape and indicate neurological impairment
symmetry of size.
 Inspect cornea for clarity and texture
Ask the client to look straight ahead. Opaque; surface not smooth may be
Hold a penlight at an oblique angle to the result of trauma or abrasion.
the eye and move the light slowly
across the corneal surface
 Assess each pupil’s reaction to
accommodation
Hold an object (a penlight or pencil)
about 10cm (4 in) from the bridge of
the client’s nose
Ask the client to look firsts at the top
of the object and then at a distant
object behind the penlight. Alternate
the gaze from the near to the far
object. Observe the pupil response.
 Assess the peripheral visual fields
To determine the function of the
retina and neuronal visual pathways
to the brain and second (optic) cranial
 Assess for visual acuity nerve.
Please watch the assessment at this site:
https://www.youtube.com/watch?
v=a9NS_RvobJw
EARS AND HEARING
 Inspect the auricles for color,
symmetry of size and position.
 Palpate the auricles for texture,
elasticity and areas of tenderness
 Inspect external ear
Excessive redness may indicate
inflammation or fever
Low set ears is associated with a
congenital abnormality (Down
syndrome)
Tenderness may indicate
inflammation or infection of external
ear.

 Visualize tympanic membrane using

an otoscope
 Assess client’s response to normal
voice tones. If client has difficulty
hearing the normal voice, proceed
with Whisper test, Tuning Fork test
(Weber’s Test and Rinne’s Test)
NOSE AND SINUSES
 Inspect the external nose for deviation
in shape, size, or color and flaring or
discharge from the nares
 Determine the patency of both nasal
cavities
 Inspect the nasal cavities using
flashlight or a nasal speculum
 Observe for presence of redness,
swelling, growths and discharge.
 Inspect nasal septum between the
nasal chambers
 Palpate the maxillary and frontal
sinuses for tenderness

Watch the assessment at this site:

https://www.youtube.com/watch?
v=qaqr2c-XEhw
MOUTH AND OROPHARYNX
 Inspect the outer lips for symmetry of
contour, color and texture.
 Inspect and palpate the inner lips and
buccal mucosa.
 Inspect the teeth and gums
 Inspect the dentures Deviations from center may indicate
 Inspect the surface of the tongue for damage to hypoglossal nerve.
position, color and texture. Dry, furry tongue (associated with
fluid deficit) white coating may be
  Inspect tongue movement oral yeast.
 Inspect the base of the tongue, the
mouth of the floor and the frenulum
 Inspect the hard and soft palate for
color, shape, texture and the presence
of bony prominences.
NECK
 Inspect the neck muscles To check for abnormal swellings
 Observe head movement
 Assess muscle strength
 Palpate the neck for enlarged lymph Deviation to one side may indicate
nodes possible neck tumor.
 Palpate trachea for lateral deviation
 Inspect the thyroid gland
CHEST (Anterior and Posterior)
Inspect: Chest expansion may
Expansion/retraction of chest wall/work of be asymmetrical with conditions such
breathing and/or accessory muscle use as atelectasis, pneumonia, fractured
Jugular distension ribs, or pneumothorax.
Auscultate:
For breath sounds anteriorly and Use of accessory muscles may
Posteriorly indicate acute airway obstruction or
Apices and bases for any adventitious massive atelectasis.
sounds
Apical heart rate Jugular distension of more than 3 cm
Palpate: above the sternal angle while the
For symmetrical lung expansion patient is at 45º may indicate cardiac
failure.

Please watch the video on assessment of chest The presence of crackles or wheezing
at must be further assessed,
documented, and reported.
https://www.youtube.com/watch? Unusual findings should be followed
v=kv3B81mWc1E up with a focused respiratory
assessment.

Auscultate anterior chest; blue dots

 indicate stethoscope placement for
auscultation

Auscultate posterior chest; blue dots

indicate stethoscope placement for
auscultation

Auscultate apical pulse at the fifth

intercostal space and midclavicular line

Note the heart rate and rhythm,

identify S1 and S2, and follow up on
any unusual findings with a focused
cardiovascular assessment.

ABDOMEN
 Inspect: Abdominal distension may indicate
ascites associated with conditions
o Abdomen for distension, such as heart failure, cirrhosis, and
asymmetry pancreatitis. Markedly visible
 Auscultate: peristalsis with abdominal distension
o Bowel sounds (RLQ) may indicate intestinal obstruction.

 Palpate: Hyperactive bowel sounds may

o Four quadrants for pain and
bladder/bowel distension (light
palpation only)
 Check urine output for frequency,
colour, odour.
 Determine frequency and type of
bowel movements.
indicate bowel obstruction,
gastroenteritis, or subsiding paralytic
ileum.
Hypoactive or absent bowel sounds
may be present after abdominal
surgery, or with peritonitis or
paralytic ileus.

Pain and tenderness may indicate

underlying inflammatory conditions
such as peritonitis.
Please watch the video on assessment of
abdomen at this site:
Unusual findings in urine output may
https://www.youtube.com/watch?
indicate compromised urinary
v=1Xc7RYkz-CE
function. Follow up with a focused
gastrointestinal and genitourinary
assessment.

Unusual findings with bowel

movements should be followed up
with a focused gastrointestinal and
genitourinary assessment.

EXTREMITIES
Inspect: Limitation in range of movement may
indicate articular disease or injury.
Arms and legs for pain, deformity, edema,
pressure areas, bruises Palpate pulses for symmetry in rate
Compare bilaterally and rhythm. Asymmetry may indicate
Palpate: cardiovascular conditions or post-
Radial pulses surgical complications.

Pedal pulses: dorsalis pedis and posterior
tibial
CWMS and capillary refill (hands and feet)
Assess handgrip strength and equality.
Assess dorsiflex and plantarflex feet against
resistance (note strength and equality).
Check skin integrity and pressure areas.
Unequal handgrip and/or foot strength
may indicate underlying conditions,
injury, or post-surgical complications.
CWMS: colour, warmth, movement,
and sensation of the hands and feet
should be checked and compared to
determine adequacy of perfusion.
Check skin integrity and pressure
areas, and ensure follow-up and in-

depth assessment of patient mobility

and need for regular changes in
position.

Assess bilateral hand strength

Palpate and inspect capillary refill and

report if more than 3 seconds.

To check capillary refill, depress the

nail edge to cause blanching and then
release. Colour should return to the
nail instantly or in less than 3
seconds. If it takes longer, this
 suggests decreased peripheral
perfusion and may indicate
cardiovascular or respiratory
dysfunction. Unusual findings should
be followed up with a focused
cardiovascular assessment.

Clubbing of nails, in which the nails

present as straightened out to 180
degrees, with the nail base feeling
spongy, occurs with heart disease,
emphysema, and chronic bronchitis.
GENITAL
Assess for presence of vaginal discharge, pain Vaginal discharge may be from an
and masses. infection
Complaints of pain in the area of the
vulva, uterus, cervic or ovaries may
indicate infection. Itching may
indicate infection or infestation.
MOBILITY
 Check if full or partial weight-bearing. Assess patient’s risk for falls.
 Determine gait/balance. Document and follow up any
 Determine need for and use of indication of falls risk. Note use of
assistive devices. mobility aids and ensure they are
available to the patient on ambulation.
Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012