Physical Examination

General Survey Provides information about the characteristics of an illness, a patient’s hygiene and body image, emotional state, recent changes in weight, and developmental status

2. Vital signs


Inspecting the patients’ temperature, pulse, respirations, and blood pressure.

3. Body Mass Index (BMI)


Determining the patient’s general level of health by determining their BMI (which reveals the normal expected weight range for a patient at a given height)

1. General Appearance & Behaviour

Body Structure


Includes build, stature, height and weight, nutritional status, symmetry of body parts, posture, and gross abnormalities

Mobility


Includes gait, movements, range of motion, and motor activity.

Physical Appearance


Includes age, gender, race, skin colour, facial features, signs of distress, physical abuse, or substance abuse.

Behaviour


Includes facial expression and mannerisms, mood and affect, speech, and hygiene.

Head (Normal Findings)


-Skull has no depressions, masses, deformities, or tenderness
-Skull is overall symmetrical and contoured
-Skull is normocephalic (Size is normal in relation to patient’s overall size)
-Facial features are symmetrical
-No involuntary movements
-Facial features are proportionate

Neck (Normal Findings)


-Neck muscles are symmetric
-Shoulders are equal in height and with average muscle mass
-Lymph nodes extend from the lower half of the head and into the neck, with no unusual enlargement, tenderness, size, consistency or warmth
-Thyroid gland is not visible, (meaning that it is normal sized and not enlarged), even when the patients’ neck is hyperextended
-Trachea is not deviated from the midline above the suprasternal notch. No masses in the neck found either.

Nose (Normal Findings)


-Nose is midline, symmetrical, and the same colour as the face
-No tenderness, swelling, masses, or deviations present
-Each nostril is patent without excessive flaring
-Nose is firm and stable
-Nasal septum is midline and intact
-Mucous membranes are deep pink and moist with no discharge or lesions
-Client can identify familiar smells without being told what the odours are and without seeing the vials containing said odours

Mouth & Throat (Normal Findings)


-Lips are darker and more pigmented than the face
-Lips are moist, symmetric, soft with no lesions
-Gums are coral pink and tight against the teeth with no bleeding
-Mucous membranes are pink and moist with no lesions
-Tongue’s dorsal surface is pink with the presence of papillae and symmetric
-Tongue’s underside is smooth with a symmetric vascular pattern
-Client can identify flavours without being told what the flavours are prior to testing and without visual aid
-Teeth are shiny, white and smooth with no discolouration
-Hard palate is whitish, intact, symmetric, firm and concave
-Soft palate is light pink, intact, smooth, symmetric, and moves with vocalization
-Uvula is pink, midline, intact, and moves with vocalization
-Tonsils are the same colour as surrounding mucosa. Also varies in size and visibility (Can be barely visible, halfway to the uvula, touching, the uvula, or touching each other or midline)
-Gag reflex is present when a tongue blade stimulates the back of the throat

Mental Status (Normal Findings)


-Eye contact
-Appropriate emotions corresponding to the conversation and situation

Eyes (Normal Findings)

Ears (Normal Findings)

Internal Structures


-Optic disc is light pink or more yellow than surrounding retina
-Retina has no lesions, is dark pink (for those with dark complexion) or light pink (for those with fair complexion)
-Arteries and veins have a 2:3 ratio with no nicking
-Only a brief glimpse at the macula without pupil dilation when client looks directly at the light

Extra-ocular Movement


-Smooth, symmetric eye movements with no jerking during testing
-Client can look straight up & down, right & left, diagonally downwards & upwards

External Structures


-Eyes are parallel with no bulging or crossing
-Eyebrows are symmetrical (in terms of alignment, hair texture, etc.)
-Eyelids closing completely and opening to show the lower border and most of the upper portion of the iris without ptosis (drooping of the eyelid)
-No edema or redness near the tear ducts
-Sclerae are white (for fair-skinned patients) and light-yellow for patient with dark complexion
-Corneas are clear, shiny and smooth
-Lenses are clear. Cloudy, if cataracts are involved.
-Irises are round and illuminating fully when light is flashed across form the side
-PERRLA (Pupils equal, round, reactive to light and accommodation)

Visual Acuity


-The client exhibits 20/20 vision when tested with the Snellen chart. This means that the client, when standing 20 feet away from an image can see what a person with normal vision can also see from 20 feet away.

Internal Structures


-Tympanic membranes are pearly grey and intact, taut, and free from tears
-Ear canals are pink with fine hairs

Hearing Acuity


-Client can hear sounds equally from both ears
-Client can hear whispering from 30 - 60 cm away

External Structures


-Auricles are of equal size and level
-Ear color matches face colour
-No present lesions, deformities, or tenderness
-No foreign bodies or discharge
-Small amount of cerumen present

Cranial Nerve Function Tests that screen the functionality of the 12 cranial nerves/ a single cranial nerve/ a related group of nerves to test for any dysfunctions or abnormalities.

Sensory Function Tests used to screen the efficiency of the sensations of pain, temperature, position, vibration, and crude and finely localized touch.

Intellectual Function Tests that screen a patient's memory, knowledge, abstract thinking, and judgement.

Motor Function Tests that are made during musculoskeletal examinations, which in addition, are used to screen the functionality of the cerebellum.

Reflexes Tests that provide data about the integrity of sensory and motor pathways of the reflex arc and specific spinal cord segments.

Visual Fields


-The client can see all objects within his/her peripheral vision when looking straight ahead
-When the client is closing one eye and the nurse is closing the eye opposite to that of the client, both the client and the nurse are seeing the same images (ex. The number of fingers the nurse is holding out) at the same time.