Physical Assessment of Various Systems

General Principles

 A complete or partial physical examination is conducted following a

careful comprehensive or problem related history.

 It is conducted in a quite, well-lit room with consideration for patient

privacy & comfort.

Approaches to the patient

 When possible, begin with the patient in a sitting position, so both

front & back can be examined.

 Completely expose the part to be examined but drape the rest of the
body appropriately.

 Conduct the examination systematically from head to toe so as not to

miss observing any system or body part.

 While examining each region, consider the underlying anatomic

structures, their functions & possible abnormalities.

 Because the body is bilaterally symmetric for the most part, compare
findings on one side with another.

 Explain all procedures to the patient while the examination is being

conducted- to avoid alarming or worrying the patient & to encourage
cooperation.
 Techniques of examination & assessment
 Inspection

 Palpation

 Percussion

 Auscultation

1. Inspection-
a) Begins with first encounter with the patient & is the most important of
all the techniques.
b) Is an organized scrutiny of the patient’s behavior & body.
c) With knowledge & experience, the examiner can become highly
sensitive to visual clues.
d) The examiner begins each phase of the examination by inspecting
the particular part with the eyes.

2. Palpation-
a) Involves touching the region or body part just observed & noting what
the various structures feel like.
b) With experience comes the ability to distinguish variations of normal
from abnormal.
c) IS performed in an organized manner from region to region.

3. Percussion-
a) By setting underlying tissues in motion, percussion helps in
determining whether the underlying tissue is air filled, fluid filled or
solid.
b) Audible sounds & palpable vibrations are produced by percussion,
which can be distinguished by the examiner.
c) The technique for percussion may be described as:

i. Hyperextend the middle finger of your left hand, pressing the distal
portion & joint firmly against the surface to be percussed.

 Other fingers touching the surface will damp the sound.

 Be consistent in the degree of firmness exerted by the hyper
extended finger as you move it from area to area or the sound will
vary.
ii. Cock the right hand at the wrist, flex the middle finger upward, &
place the forearm close to the surface to be percussed. The right
hand & forearm should be as relaxed as possible.
iii. With a quick, sharp, relaxed wrist motion, strike the extended left
middle finger with the flexed right middle finger, using the tip of the
finger. Aim at the end of the extended left middle finger where the
greatest pressure is exerted on the surface to be percussed.
iv. Lift the right middle finger rapidly to avoid damping the vibrations.
v. The movement is at the wrist, not at the finger, elbow, or shoulder.
The examiner should use the lightest touch capable of producing a
clear sound.

4. Auscultation-
a) This method uses stethoscope to augment the sense of hearing.
b) The stethoscope must be constructed well & must fit the user. Ear
pieces should be comfortable, the length of the tubing should be 25-
38cm, & the head should have a diaphragm & a bell.

 The bell is used for low pitched sounds such as certain heart
murmurs.
 The diaphragm screens out low pitched sounds & is good for hearing
high frequency sounds such as breath sounds.
 Extraneous sounds can be produced by clothing, hair, & movement of
the head of the stethoscope.

Equipments
 Thermometers

 Cotton applicator stick

 Sphygmomanometer

 Stethoscope

 Oto- ophthalmoscope

 Reflex hammer

 Flash light
 Tuning fork

 Tongue depressor

 Safety pin

Techniques
 Vital signs-

 Temperature

 Pulse

 Respirations

 Blood pressure

 Height & weight

 General appearance

 Race

 Sex

 General physical development

 Nutritional state

 Mental alertness

 Evidence of pain

 Restlessness

 Body positions

 Clothes

 Apparent age
 Hygiene

 Grooming

 Skin

 Inspection

 Skin color, pigmentation, lesions, jaundice, cyanosis, scars,

superficial vascularity, moisture, edema, color of mucous
membranes, hair distribution, nails.

 Palpation

 Temperature, texture, elasticity, turgor.

 Head

 Inspection

 Symmetry of face, configuration of skull, hair color & distribution,

scalp.

 Palpation

 Hair texture, masses, swelling or tenderness of scalp, configuration of

scalp.

 Eyes & vision

 Inspection

 Globes

 Palpebral fissures

 Lid margins

 Bulbar & Palpebral conjunctivae

 Sclera

 Pupils

 Eye movement

 Gross visual fields

 Visual acuity

 Palpation

 Strength of upper lids, tenderness & tension.

 Ears & Hearing

 Inspection

 Pinna- size, shape, color, lesions, masses.

 External canal- Discharge, impact cerumen, inflammation, masses,

foreign bodies.

 Tympanic membrane- color, luster, shaper, position, transparency,

integrity, scarring.

 Landmarks- cone of light, umbo, handle & short process of the

malleus, pars flaccida, pars tensa.

 Palpation

 Pinna- tenderness, consistency of cartilage, swelling.

 Mechanical Tests-
 Weber test- Test for lateralization of vibration. Place tuning fork in
the center of the scalp near the forehead. Normally sound is heard
equally in both ears.
 Rinne test- compares air & bony conduction.
a) Place vibrating tuning fork on the mastoid process behind the ear &
have the patient tell you when the vibration stops.
b) Then quickly hold the buzzing end of the tuning fork near the canal &
ask if patient can hear it.
 Nose & Sinuses

 Inspection

 General deformity

 Nasal septum

 Discharge

 Nasal obstruction

 Airway patency, Mucous membranes

 Palpation

 Sinuses- ( frontal & maxillary ) for tenderness

a) Frontal- direct manual pressure upward toward wall of sinus. Avoid

pressure on eyes.

b) Maxillary- with thumbs, direct pressure upward over lower edge of

maxillary bones.

 Mouth

 Inspection

 Lips- color, moisture, pigment, masses, ulcerations, fissures.

 Teeth- number, arrangement, general condition.

 Gums- color, texture, discharge, swelling, retraction.

 Buccal mucosa - discoloration, vesicles, ulcers, masses.

 Pharynx- inflammation, exudate, masses.

 Tongue- size, color, thickness, lesions, moisture, symmetry.

 Salivary glands- sublingual, submaxillary glands.

 Uvula
 Tonsils- size, ulceration, exudates, inflammation.

 Odor of breath

 Voice

 Palpation- Examine oral cavity for masses & ulceration. Palpate

beneath tongue & explore laterally the floor of the mouth.

 Neck

 Inspection- inspect anteriorly, posteriorly for masses, symmetry,

masses, unusual swelling, pulsation, range of motion.

 Palpation- cervical nodes, salivary glands, trachea, thyroid, carotid

arteries.

 Lymph nodes

 Inspection- size, shape, consistency, tenderness & inflammation.

 Palpation-

 cervical, supra-& infraclavicular nodes.

 Axillary nodes

 Inguinal nodes

 Epitrochlear nodes

Female breast

 Inspection

 Inspect areolae & nipples for position, pigmentation, inversion,

discharge, crusting, masses.
 Examine breast tissue for size, shape, color, symmetry, surface,
contour, skin characteristics & level of breast.

 Palpation- skin texture, moisture, temperature, & masses.

 Male breast- Observe nipple & areola for ulceration, nodules,

swelling, discharge & palpate areola.

Thorax & lungs

 Posterior

 Inspect the spine for mobility & structural deformity.

 Observe symmetry & posture, mobility on respiration.

 Palpation Identify areas of tenderness, masses, inflammation.

 Palpate the ribs & costal margins for symmetry, mobility, tenderness.

 Percuss symmetric areas, comparing sides.

 Note & localize any abnormal percussion sounds.

 Auscultation aids in assessing air flow through the lungs, the

presence of fluid or mucous.

 Anterior

 Inspect the chest for any structural deformity.

 Observe rate & rhythm of breathing, bulging or retraction of

intercostals spaces on respiration, use of accessory muscles of
respiration.
 Note any asymmetry of chest wall movement on respiration.

 Palpation- To assess diaphragmatic excursion, symmetry & degree

of expansion.

 Percuss & note the intercostal space where hepatic dullness is

percussed on the right & cardiac dullness on the left.

 Auscultation- Listen to the chest anteriorly & laterally of the

distribution of resonance & any abnormal or adventitious sounds.

 Heart

 Inspection- Precordium of any bulging, heaving, or thrusting. Look

for apical impulse. Note any other pulsation.

 Palpate for the thrill & pulsation in each areas.

 Percussion

 Auscultation- identify the 1st (S1) & 2nd (S2) heart sounds.

 Peripheral circulation

 Jugular veins

 Inspect neck for internal jugular venous pulsation.

 Extremities

 Inspection- observe skin over extremities for color, pallor, rubor, hair
distribution.

 Palpation- note temperature of skin over extremities, palpate pulses,

observe for edema.
 Abdomen

 Inspection- observe general contour of the abdomen, symmetry,

visible peristalsis, aortic pulsations. Check the umbilicus for hernia,
skin rashes, striae & scars.

 Auscultation- Listen over the aorta & renal arteries for bruits. Note
the frequency & character of bowel sounds.

 Percussion

 Palpation-perform light palpation to detect any muscular resistance,

tenderness, superficial organs or masses. Palpate liver, spleen ,
kidneys, aorta etc.

Male genitalia & hernias

 Inspection- Inspect the pubic hair distribution, skin of penis, glans

penis, observe urethral meatus, ulcers, masses, scars & discharge.

 Observe the skin of the scrotum, note size, contour, redness, swelling
& symmetry.

Palpation- Palpate any lesion, nodules, masses, tenderness,

contour, shaft of the penis for induration, testis & epididymis,
spermatic cord, palpate for inguinal hernias. Also palpate for the
hernia in the femoral canal.

Female genitalia

 Inspection- Inspect for the pubic hair distribution, labia majora, mons
pubis, perineum, clitoris, urethral meatus, vaginal opening. Note skin
color, ulceration, nodules, discharge, swelling.

 Palpation- Note nodules, masses, irregularities anteriorly &

posteriorly. Locate the cervix & fornices.
 Rectum (male & female)

 Inspection- Inspect the anus, perianal region, sacral region for

inflammation, nodules, scars, lesions, ulceration, rashes.

 Palpate any abnormal area noted on inspection. Note sphincter tone,

nodules, masses & tenderness.

Musculoskeletal system

 Inspection- Inspect the upper & lower extremities for size, symmetry
& deformity & muscle mass. Inspect the joints for ROM, enlargement,
redness. Note gait & posture, observe the spine for ROM, lateral
curvature, any abnormal curvature.

Palpation- Palpate the joint of the upper & lower extremities & the
neck for tenderness, swelling, temperature& ROM. Palpate the
muscles for size, tone, strength & tenderness, spine for bony
deformities & crepitation.

Neurologic system

 Components of neurological examination:

 Mental status

 Cranial nerve function

 Cerebellar function

 Motor function

 Sensory function

 Deep tendon reflexes

Mental status
 State of consciousness( alert, somnolent, stuporous, comatose)

 Memory( short term, long term, intermediate)

 Cognition( calculations, current events)

 Affect( mood)

 Ideational content( hallucinations)

Cranial nerve function

 First cranial nerve (olfactory) It is only assessed when patient

complains of a disturbance in sense of smell.

 Second nerve (optic)- Includes tests of visual acuity & gross visual
field.

 Third nerve (occulomotor) Fourth (trochlear) &

sixth( abducens)nerves- Are tested together. These nerves control
the movements of the extraocular muscles of the eye.

 Fifth nerve (trigeminal)- Has motor component that controls

muscles of mastication & a sensory component that controls
sensations of the face.

 Seventh nerve (facial)- motor function is tested by observing facial

expressions & symmetry of facial movement. Ask the patient to frown,
close his eyes & smile.

 Eight nerve (acoustic)- Has two branches cochlear(Mediates

hearing) & vestibular( helps control equilibrium).

 Ninth nerve (Glossopharyngeal) & tenth (vagus)- Are tested

together because both have a motor portion innervating the pharynx.
 Eleventh nerve (spinal accessory)- mediates the
sternocleidomastoid & upper portion of the trapezius muscles.

 Twelfth nerve (hypoglossal)- innervates muscles of the tongue.

Test by noting articulation & by having the patient stick out his
tongue, noting any deviation or asymmetry.

Cerebellar function

 Observe posture & gait, muscle coordination in lower& upper

extremities.

Motor function- Evaluate muscle mass, tone, strength, abnormal

movements & symmetry.

Sensory function

 Test sensitivity to light touch, pain, vibration & position.

Deep tendon reflexes

 Upper extremities

 Biceps- Place your right thumb on the patients right biceps tendon.
Rest the patients forearm on your left hand & strike your thumb with
the pointed end of the hammer head. Hold the hammer loosely so it
pivots in your hand when it is moved with a wrist action.

 Triceps tendon- Have the patient hang his arm freely, while you
support it with your non-dominant hand. With the elbow flexed, strike
the tendon directly using the pointed end of the hammer.

 Brachioradialis tendon- Strike the forearm with the hammer about

2.5cm above the wrist over the radius. Be sure the forearm is
supported & relaxed.
 Lower extremities

 Quadriceps reflex-Have the patient sitting with his legs hanging over
the edge of the table or lying down while you support the legs at the
knee. If reflexes are difficult to elicit, have the patient interlace the
fingers of both hands & then have patient try to pull his hand apart.

 Achilles reflex- Support the foot in dorsiflexed position. Tap the

Achilles tendon with the hammer head. The foot should move
downward into your hand.