PHYSICAL EXAMINATION

Afnan .Y. Toonsi

THORAX AND LUNG
 Posterior thorax

Inspection:
 Inspect the Shape and symmetry
 Inspect the Spinal alignment for deformities
Normally chest is symmetric and spine is vertically aligned
 To assess for lateral deviation of the spine (scoliosis):
- Observe the standing client from behind
- Have the client bend forward at the waist and observe
- Normally spinal column is straight, right and left
shoulders and hips are at the same height.
 Chest deformities:
- Pigeon, Funnel, Barrel, Kyphosis, Scoliosis
Palpation:
 Assess the temperature and integrity of all chest skin
 Palpate for bulges, tenderness, or abnormal movements
 Palpate for respiratory excursion (expansion)

 Normally the thumbs separate 3 to 5 cm during deep

inspiration
Palpation: (cont.)
 Palpate for vocal (tactile) fremitus
 Place your hand on the posterior chest
 Ask the patient to repeat numbers as “one,two,three”

 Normally there is a bilateral symmetry of vocal fremitus.

 Decreased or absent fremitus associated with pneumothorax
 Increased fremitus associated with pneumonia
Percussion:
Percussion of the thorax is performed to determine whether
underlying lung tissue is filled with air, liquid, or solid
material and to determine the positions and boundaries of
certain organs.
 Ask the client to bend head and fold the arms forward
across the chest.
 percuss in ICS at about 5 cm interval in systematic sequence

 Normally , percussion notes resonance over the lung and

flatness over the ribs
 Areas of dullness or flatness over the lung associated with
consolidation of lung tissue or mass.
Percussion :(cont.)
 percuss for diaphragmatic excursion (movement of the
diaphragm during maximal inspiration and expiration)

A-Ask the client to take deep breath and hold it while

you percuss downward along the scapular line until
dullness is produced at the level the diaphragm , mark
this point .
B-Ask the client to take a few normal breath and expel
last breath completely and hold it while you percuss
upward from the marked point .
C-Measure the distance between 2 marks
 Excursion is 3 to 5 cm bilaterally in women and 5 to 6
cm in men.
Auscultation:
 Use systematic zigzag as in percussion .
 Ask the client to take slow, deep breaths through the
mouth and listen to breath sound during complete inspiration
and expiration.
 Compare findings at each side
 Anterior Thorax
Inspection:
 Inspect the breathing pattern (rate & rhythm)
 Inspect the costal angle
 Normally , costal angle is less than 90 degree.
Palpation:
 Palpate the anterior chest for respiratory excursion.
 Palpate for tactile fremitus .
 Normally, same as posterior vocal fremitus, fremitus
decrease over heart and breast tissue.

 Done by using two hands that are placed simultaneously

on the corresponding area of each side of the chest
Percussion:
 Percuss the anterior chest begin above the clavicles in
the supraclvicular space and proceed downward to the
diaphragm.
 Normally, percussion notes resonance down to 6th rib at
the level of the diaphragm but flat over bone or
muscle, dull over heart and liver, and tympanic over the
stomach
Auscultation:
Normal breathing sounds:

Type Location characteristics

Vesicular Base of the lung Inspiration lasts longer
than expiration
Broncho-vesicular 1st & 2nd ICS Equal inspiratory and
expiratory phases
Bronchial Over the trachea Expiration last longer
than inspiration

Abnormal breathing sounds

Name Cause Description

Crackles Fluid & mucus Rolling hair together
Gurgles(rhonchi) narrowing Sound with a snoring quality
Friction rub Rubbing Grating sound
wheeze Constricted Squeaky musical sound
bronchus
CARDIOVASCULAR AND PERIPHERAL
VASCULAR SYSTEM
LOCATING THE ANATOMIC SITES OF THE
PRECORDUIM
Inspection, palpation & auscultation:
1- Inspect and palpate the aortic, pulmonic, tricuspid, apical
area for pulsations, lifts or heaves.
2- Inspect and palpate the epigastric area at base of
sternum for abdominal aortic pulsations.
3- Auscultate the heart in 4 anatomic area .( the aortic,
pulmonic, tricuspid, apical area ).
Normally:
- no pulsation except in epigastric area, no lift or heave
- S1 louder at the apex of the heart, S2 louder at the base
- S3 in children and young adults
- S4 in many older adults
Carotid arteries:
 Palpate the carotid artery with cautions.
 Palpate only one carotid artery and avoid exerting too
much pressure and massaging area
 Auscultate the carotid artery for presence of bruit, if
present gently palpate the artery to determine the
presence of thrill
Jugular veins:
 Inspect the jugular veins for distention while the client
is placed in semi-fowler's position with head supported
on a small pillow.
 Normally, veins not visible ( right side of heart is
functioning normally ).
 Assessing the peripheral vascular system:
 Peripheral pulses:

Palpate the peripheral pulses on both sides

o Peripheral veins
 Inspect the peripheral veins in the arms and legs for
presence of superficial veins when limbs are dependent
and limbs are elevated .
 Normally , in dependent position , presence of
distention and nodular bulges.
 When limbs elevated , veins collapse .
 Assess the peripheral leg veins for signs of phlebitis.
 Normally, limbs not tender , symmetric in size
 Peripheral perfusion:
 Inspect the skin of the hand and feet for color,
temperature, edema and skin changes.
 Assess the adequacy of arterial flow if arterial
insufficiency is suspected by two method :
 Buerger's test ( arterial adequacy test ):
 Put the client in supine position, raise one leg or arm about
30 cm above heart level, move foot or hand briskly up and
down about 1 minutes, then sit up and dangle the leg or
arm .
 Observe the time elapsed until return of original color and
vein filling . Original color normally return in 10 seconds
and vein filling in about 15 seconds.
 Capillary refill test
 Documentation .
 BREAST AND AXILLAE
Inspection:
 Inspect the breast for size, symmetry, contour or shape
while the client is in a sitting position.
 Inspect the skin of the breast for localized discoloration or
hyperpigmentaion, retraction, localized hypervascular area,
swelling or edema.
 Emphasize any retraction by having the client :
 Raise the arms above the head .
 Push the hand together with elbows flexed.
 Press the hand down on hip.
 Inspect the areolas for size, shape, symmetry, color,
surface characteristic and any masses or lesion.
 Inspect the nipples for size, shape, color, position,
discharge and lesion.
Palpation:
 Palpate the axillary ,subclavicular and suparclavicular
lymph nodes. Assess axillary lymph nodes while client
sits with arms abducted and supported on the nurse
forearm.
 Palpate the breast for masses ,tenderness and any
discharge from nipple.
 Put the client in supine position .
 Instruct the client to abduct the arm and place her
hand behind her head and then place small pillow under
client shoulder.
 Use the palmar surface of the middle three fingertips .
 Choose one of three pattern for palpation :
 a. Hand of the clock or spokes on wheel.
 b. Concentric circles pattern .
c. Vertical strips pattern .
 Palpate the areola and the nipples for masses or discharge
by compressing
 (amount, color, consistency ,odor ).
 Teach the client the technique of breast self examination.
 Documentation.
ASSESSING THE ABDOMEN
Inspection:
 Inspect the abdomen for skin integrity.
 Inspect the abdomen for contour and symmetry .
a-Observe abdominal contour while standing at the client
side when the client is supine.
b-Ask the client to take a deep breath and hold it.
c-Assess the symmetry of contour while standing at the
foot of the bed.
d-If distention is present ,measure the abdominal girth at
the level of umbilicus.
 Observe abdominal movements associated with respiration,
peristalsis or aortic pulsations.
 observe the vascular pattern.
Auscultaion:
 Auscultate the abdomen for bowel sound and vascular
sound
 Listen for active bowel sounds every 5 to 20 seconds
 Normal bowel sounds are described as audible, absent,
hypoactive or hyperactive
 For vascular sounds use the bell over the aorta, renal
arteries, iliac arteries, and femoral arteries
 Listen for bruits.
 Normally absence of arterial bruits
 Loud bruit over aortic area indicate aneurysm
Percussion of the abdomen:

 Percuss in the 4 quadrant starting from the right lower

quadrant proceeding to the left lower quadrant.
Percussion of the liver:
 Percuss the liver to determine its size ( 6 to 12 cm) at
midclavicular line or( 4 to 8 cm ) at the midsternal line.
Palpation:
 Perform light palpation first for tenderness or muscle
guarding.
 Light palpation:
 Hold the palm of your hand parallel to the abdomen .
 Depress the abdomen wall about 1 cm in depth
 Move the finger pads in slightly circular motion .
 Note any tenderness, ask the client to tell you about
them and look for patient facial expression .
 Deep palpation:
 Perform deep palpation over all 4 quadrant.
 Press the distal half of the palmer surface of fingers
of one hand into abdominal wall .
 Depress the abdominal wall about 4 to 5 cm .
 Normally, tenderness may be present near xiphoid
process, over cecum and over sigmoid colon.
 Check for rebound tenderness at the areas of pain
which indicates peritoneal inflammation
Palpation of the liver:
 Palpate the liver to detect enlargement and tenderness
 Stand on the client right side .
 Place your left hand on posterior thorax about 11 th and
12th rib .
 Place your right hand parallel to the rectus muscle with
fingers pointing toward the rib cage.
 During exhalation palpate with a depth of 4 to 5 cm
 Maintain your hand position & ask the client to inhale
deeply, while the client inhale, feel the liver border move
against your hand.
Palpation of the bladder:
 Palpate the area above pubic symphysis if the client
has a history of urinary retention
 Normally, not palpable .
 Documentation.
MUSCULOSKELETAL SYSTEM
 Muscles:
 Inspect the muscles for size .
 Inspect the muscles and tendons for contracture.
 Inspect the muscles for tremor. Inspect any tremors
of hand and arm by having the client hold the arm out
in front of the body.
 Palpate muscles at rest to determine muscles tonicity .
 Palpate muscles for flaccidity ( weakness or laxness ),
spasticity ( sudden involuntary muscle contraction ) and
smoothness of movement.
 Test muscles strength.
 Sternocleidomastoid:
 Trapezius:  Deltoid :  Wrist & fingers:

 Biceps:  Triceps:  Grip strength:


 Hip adduction:  Hip abduction:
 Hip muscles:  Quadriceps:

 Hamstrings:  Dorsiflexion:
 Bones:
 Inspect the skeleton for normal
structure and deformity.
 Palpate the bone to locate any area of
edema and tenderness.
Joints:
 Inspect the joint for swelling, Palpate
each joint for tenderness, smoothness
of movement, swelling and presence of
nodules.
 Assess joint range of motion. The
amount of joint movement can be
measured by goniometer ,device that
measure the angle of joint in degree.
 Documentation.
 ASSESSING THE NEUROLOGICAL
SYSTEM
 Language:
If the client displays difficulty speaking:
 Ask the client to name common objects.
 Ask the clients to respond to simple commands as raise
your arm

 Orientation:
 Determine the client orientation to time , place and
person by questioning .

 Memory:
 Ask the client about difficulty with memory
 If problem apparent, 3 categories of memory are
tested:
 Immediate recall, recent memory and remote memory
 To assess immediate recall:
 Ask the client to repeat series of three digit
e.g. 7-4-3 ,spoken slowly and gradually increases no of
digit e.g. 7-4-3-5-6-2 and ask client repeat correctly
 The average person can repeat 5-8 digits in sequence

 To assess recent memory :

 Ask the client to recall the recent events of day such
as how to got the clinic.

 To assess remote memory :

 Ask client to describe previous illness or surgery,
birthday or anniversary.
 Attention span and
calculation:
 Test the ability to concentrate
and maintain attention. Ask the
client to count back from 100 or
ask client to subtract 7 or 3
progressively from 100 .

 Level of consciousness:
 Apply the Glasgow coma scale .
 Assessment totaling 15 point
indicate the client is alert and
completely oriented .
 Comatose client score 7 or less.
 Cranial nerves
Cranial :Name :Type Function Assessment
:nerves Method
I Olfactory sensory Smell Identifying
aromas
II Optic sensory Vision Snellen chart

III Oculomotor motor movement of ,)EOM( Assess six ocular

sphincter of pupil, movement
movement of ciliary
.muscles of lens
IV Trochlear motor Moves eyeball Assess six ocular
downward & laterally movement
V Trigeminal Sensory Sensation of cornea, - Blink reflex
Opthalmic - skin of face & nasal - Test light
branch mucosa sensation
Maxillary - Sensory Sensation of skin of
Branch face, tongue & teeth

Mandibular - Motor & - Ask client to

Muscles of mastication
branch sensory clench teeth
VI Abducens Motor EOM, moves eyeball Assess directions
laterally of gaze
 Cranial nerves (cont.)

Cranial Name Type Function Assessment

nerve method
VII Facial Motor & Facial expression -Ask client to
sensory taste smile, frown, etc
-Identifying
tastes
VIII auditory sensory Equilibrium and -Romberg test
hearing -tuning fork
IX Glosso- Motor and Swallowing ability -Swallow
pharyngeal sensory tongue movement -move tongue
X vagus Motor and Sensation of Assess speech for
sensory pharynx and hoarseness
larynx, swallowing
vocal cord
movement
XI Accessory motor Head movement Shrug shoulder
shrugging of against resistance
shoulder
XII hypoglossal motor Tongue movement Protrude tongue
 Reflexes
 Biceps  Brachioradialis  Achilles

 Triceps  Patellar  Plantar

 Motor function:
 Balance Tests:
1. Walking Gait:

2. Romberg Test:
Ask the client to stand with
feet together and arm resting at
the side first with eye close and
open .

3. Standing on one foot with eyes

closed

4. Heel-Toe Walking:
Ask the client to walk a straight
line, placing the heel of one foot
directly in front of toe of the
other foot
5. Toe or Heel Walking:
6. Finger to Nose test:
7. Alternating supination and
pronation of hands on knees:

8. Finger to nose and to the

nurse’s finger
9. Fingers to fingers:

10. Fingers to thumb:

 Fine motor tests for lower extremities:
1. Heel down opposite shin

2. Toe to the nurse’s finger

 Sensory function:
 Light – touch sensation (by cotton)
 Pain sensation (tongue depressor)
 Temperature sensation
 Kinesthetic sensation
 Tactile discrimination
 One and two point discrimination
 Sterognosis ( ability to recognize object by touching them).

 Documentation.
 ASSESSING THE FEMALE GENITALS &
INGUINAL AREA
 Inspect the distribution, amount and characteristics of
pubic hair .
 Inspect the skin of the pubic area for parasites ,
inflammation, swelling and lesion .
 Inspect the clitoris, urethral orifice and vaginal orifice
when separating the labia minor.
 Palpate the inguinal lymph nodes in a rotary motion,
noting any enlargement or tenderness.
 Document findings.
 ASSESSING RECTUM & ANUS

 Inspect the anus and surrounding tissue for color,

integrity and skin lesion ask the client to bear down .
Bearing down create slight pressure on the skin and
allow you to see rectal fissure, rectal prolapse, polyps
& internal hemorrhoids.
 Palpate the rectum for anal sphincter tonicity ,
nodules, masses and tenderness.
 Lubricate your gloved finger and ask the client to bear
down
 Insert your finger and palpate for a distance of 6 to
10 cm
 Documentation .