PHYSICAL EXAMINATION

General appearance
Nourishment - well nourished/ moderate nourished/ mal nourished
Health - healthy/unhealthy
Body built - thin /moderate /obese
Activity - active/dull
Hygiene - good/bad

Mental status examination

Consciousness - conscious/ semi-conscious /un -conscious
Orientation - oriented to time /place/person
Look - pleasant/happy/alert/sad/depressed/fearful/anxious/tired/drowsy

Anthropometric measurements:
Height -___________cms
Weight -___________kgs
BMI - kg /m2

Vital signs
Temperature - 98oF
Pulse -__________beats/minute
Respiration -__________breaths/minute
Blood pressure -__________mm of Hg
Pain - |--|--|--|--|--|--|--|--|--|--|
0 1 2 3 4 5 6 7 8 9 10

HEAD TO TOE ASSESSMENT

Integumentary system
Skin
Colour -fair/brown/dark in complexion
Texture -normal/dry
Skin turgor - normal/decreased
Hydration -good moderate/dehydrated
Discoloration -absent/yellowish/cyanosis/vitiligo/pallor/increased pigmentation
Lesions/masses -absent/macule/papule/nodule/vesicle/pastule
Subjective symptoms -no complaints/pain/feeling of cold/warmth tingling/ Numbness

Nails
On observation -intact/onycholysis/peeling or cracking/paronychia
Nail beds -pink/cyanosis/pale
Nail plate -absent/flat/clubbing/whitening
Capillary refilling - ___seconds
Other sign symptom - if any_______

Hair
Colour -black/brown/red/grey/dyed
Texture -normal/dry
Grooming -not groomed/well groomed
Distribution -normal/scanty/bald/alopecia
Other signs/ symptoms - if any__________

Head
Shape -normocephalic/micro/macro /hydrocephalic
Scalp -clean/pediculosis/presence of dandruff/any scar
Face -puffiness/moon face/bell’s palsy/normal
Subjective symptoms- no complaints/if any_________
CNS: Inspect the face for expression, shape, symmetry (CN VII), symmetry of eyes, eyebrows, ears,
nose and mouth. Instruct the patient to raise the eyebrows, frown, smile, wrinkle the forehead, show
the teeth, purse the lips, puff the cheeks and whistle (CN VII). Palpate the temporal pulses. Palpate
the temporalis muscles (CN V). Palpate the masseter muscles (CN V).

Eyes
Eyebrows -symmetrical/equally distributed/asymmetrical /scanty
Eye lashes -absent /equally distributed/presence of dandruff
Eye lids -normal/edematous/ptosis
Pupilliary reflex -reacting to light/unequal reaction (specify which eye)
Pupil shape -round/oval/irregular/pin pointed
Pupil size -pins pointed/2mm/3mm/dilated
Sclera -white/reddish/yellowish
Conjunctiva -normal/ pale/ yellowish/ conjunctivitis/vitamin A deficiency
Vision -normal/Myopia/ presbyopia/ hyperopia/ astigmatism (specify including use of
spectacles)
Subjective symptoms-no complaints/pain/itching/increased tear production/decreased tear production
CNS: Test distance vision and near vision (CN II). Test visual fields via confrontation (CN II).
Assess extraocular muscle mobility: cover/uncover test, corneal light reflex, six cardinal fields of
gaze (CNs III, IV, VI). Assess direct and consensual light reflexes and accommodation (CN III).

Ears
Pinna -normally placed/anotia/microtia/macrotia/melotia
Cerumen -absent/packed with
Ottorhoea -absent/purelent/serous/bloody
Hearing -normal/decreased (specify)
Subjective symptoms -no complaints/otalgia/tinnitus/vertigo/autophony
CNS: Test gross hearing: voice-whisper test or watch-tick test (CN VIII)

Nose
Nasal septum -midline/deviated
Nasal pathway -patent/obstructed/nasal polyp
Smell -normal/absent
Rhinorrhoea -absent/watery/purelent/mucoid/epistaxis
Frontal and maxillary sinuses -painful/tender/sinusitis/no complaints
Subjective symptoms -any other (specify)
CNS: Test olfactory sense (CN I).

Mouth and pharynx

Lips -dry/cracks:symmetrical/asymmetrical
Colour -pink/pale/dark
Gums - Colour-pink/pale/dark/bleeding/gingivitis
Tongue -moist/dry/coating/lesions/ankyloglossia
Position -midline/deviated
Mobility -voluntary/not possible
Colour -pink/pale/reddish/dark
Taste -normal/absent
Teeth -dental caries/decay/dentures/colour-white/yellowish/stains
Breath odour -halitosis-present/absent: Fetid-present/absent
Pharynx -sore throat/infection/pain/irritation
Gag reflex -present/absent
Tonsils -colour, enlarged/not enlarged/painful
Voice -clear/harsh/aphonia/dyphonia
Subjective symptoms- no complaints/toothache/dysphagia/ odynophagia/throat pain
CNS: Inspect the tongue; ask the patient to stick out the tongue (CN XII). Inspect the uvula; note
movement when the patient says ‘ah’ (CNs IX, X). Test gag reflex (CNs IX X). Test taste (CN VII).

Neck
Range of motion -possible/painful/absent
Lymph nodes -not enlarged/enlarged/painful
Trachea -midline/deviated
Thyroid gland -not enlarged/enlarged/removed
Jugular veins -distended/not distended
Subjective symptoms-no complaints/if any
CNS: Inspect range of motion, should shrug, and strength of sternocleidomastoid and trapezius
muscle (CN XI).

Chest
Inspection : Symmetrical/asymmetrical/flat/barrel chest
Thorax expansion-normal and equal/delayed/shallow/unequal
Cough - absent/if present (dry/whooping/productive)aggravating factor if any
Respiratory rate ____ b/m
Palpation : Chest wall - Crepitus, Plural friction rub
Vocal(Tactile) Fremitus - Abnormal Findings: Increased (tumor, lobar pneumonia),
decreased ( obstruction of the airway by fluid , air , calus in the pleura )
Tenderness
Percussion : Normal – Resonance, Dullness – Fluid filled/ Haemothorax/ Empyema (pus collection),
Hyperresonance – emphysema (abnormal increase in the size of the air spaces)
Auscultation : Heart sounds -S1, S2/murmur /gallop sounds
Breath sounds -normal/wheeze/friction rub/bronchi/crackles/stridor
Apical pulse - ____beats/min
Subjective symptoms- no complaints/ diaphoresis /dyspnoea / giddiness/palpitations/chest
pain/shoulder pain/chest tightness/exercise intolerance / Sputum - absent/if present specify the
following Odour: absent/bad odour, Consistency: frothy/mucoid/rusty/sticky/purelent, Colour:
green/yellow/blood stained/ any other
Abdomen
Inspection :Flat/abdominal pulsation seen/linea niagra /distension/pigmentation
/scar/hernia/peristaltic movement seen/striae/keloid,
Umbilicus-clean/infected/everted, abdominal girth in cms, dressing, wound drainage
Auscultation : Bowel sounds - present/absent/no. of count -------/minute
Palpation : Tenderness, Inguinal lymph nodes-enlarged/not enlarged/movable/painful
Percussion : fluid/masses/air
Subjective symptoms - no complaints/nausea/vomiting/heart burn /abdominal
cramps/belching/flatulence/abdominal pain
Any other signs /symptoms-_______________

Musculo skeletal
Posture curves -normal/kyphosis/lordosis/scoliosis
Muscle tone -normal/hypertonia/hypotonia/flaccid/spastic/rigid
Muscle strength -normal/weaker than normal/hyperactive

Upper extrimities
Symmetry -symmetrical/asymmetrical
Finger nails -capillary refilling _____seconds
Range of motion -possible/if impossible(specify)____
Peripheral pulse -Radial:- rate,rhythm,volume,(normal/abnormal) If abnormal (specify)-__
Brachial rate,rhythm,volume,(normal/abnormal) If abnormal (specify)__
Reflexes -Biceps- normal/abnormal
Triceps -normal/abnormal
Oedema /swelling -absent/if present (specify area)______
Cyanosis -absent/if present (specify area)______
Joints-no complaints/swollen/stiff/tendor/crepitus_______
Deformity -absent/if present (specify)
Other signs/symptoms-/if any_______

Lower extrimities
Symmetry -symmetrical/asymmetrical
Toe nails -capillary refilling _____seconds
Range of motion - possible/if impossible (specify)____
Peripheral pulses -Dorsalis pedis:- rate,rhythm,volume,(normal/abnormal) If abnormal (specify)
Posterior tibial- rate,rhythm,volume,(normal/abnormal)If abnormal (specify)
Popliteal -rate,rhythm,volume,(normal/abnormal)If abnormal (specify)
Reflexes-patellar -normal/abnormal
Achilles tendon - normal/abnormal
Plantar - normal/abnormal
Oedema/swelling absent/if present (specify area)______
Cyanosis - absent/if present (specify area)______
Joints - no complaints/swollen/stiff/tendor/crepitus_______
Deformity - absent/if present (specify area) ______
Gait - normal/limp/steppage/scissoring/dystonic/ataxia
Varicose veins - absent/if present (specify area) ______
Other signs/symptoms-none/if any
Dependency level-independent/partial/dependent/fully dependent
Genito urinary
Lesions /scar- absent/if present (specify area) ______
Discharge /infection -absent/if present (specify area) ______
Voiding-continent/incontinent/catheterised
Colour of urine___________
Subjective symptoms-no complaints/dysuria/pruritis/nocturia/oliguria /any other
Rectum and anus
Perianal skin integrity-intact/excoriation/rashes/lesions/ haemorrhoids/bleeding
Bowel elimination pattern – Normal/constipation/loose stools/diarrhea
Subjective symptoms – pain before or while passing stools/blood or mucus in stools/rectal mass/ any
other__________

IMPRESSION