1

GENERAL ORDER OF THE EXAM *

• Inspect → visually observe pt

• Palpate → use hands to feel pt

• Percuss → light striking of body parts to

produce sounds

• Auscultate → listening to body w/stethoscope

o Bell = low-pitch sound

o Diaphragm = high-pitch sound *All systems except GI

4 CLASSICAL ASSUMPTIONS

• A & O x 4 (person, place, time, situation)

• Vital signs WNL

• Visual acuity assessed via Snellen chart

(CN 2 – Optic)

• Patient is in NAD

PREPARATION

• Knock on entry

• Introduce yourself

o “Hi, my name is Sumiyah, and I’m a

nursing student. I will be performing

a physical exam on you today.”

• Hand hygiene

GENERAL SURVEY

• Physical Appearance

o Age, sex, race/ethnicity

• Body Structure

o Tall/short

o Underweight/overweight/average weight

o Proportionality of weight to height

• Mobility

o Ease in ambulation

o Ease in movement of limbs

• Behavior/Mood

o Response to questions

o Grooming/hygiene

o Affect/speech/eye contact

Ex: “Pt is a (#) y/o (gender ident.) of avg. &

proportional height & weight, who moves easily

& responds to questions. They are well groomed

& have appropriate affect to situation.”

SKIN

Inspect

• Entire body → color, lesion, hair distribution

• Finger/Toenails → pitting or clubbing

• Describe lesions noting number, location,

arrangement & type & document later

Palpate (Use the back of the hand)

• Moisture, temperature, texture, turgor

(pinch back of hand), checking for tenting

• Note areas of tenderness or induration

“I will continue to inspect the rest of the body

bilaterally throughout the remainder of my

exam”

HEAD → NCAT

Inspect

• Skull → general size & contour

• Scalp → lesions or inhabitants

• Hair → quantity, texture, distribution, balding

• Face → symmetry (eyebrows, palpebral

fissures in line with helices of ears, nasolabial

folds)

Palpate

• Skull → deformities or tenderness

• Temporal Artery → induration & intensity

(2+ = normal)

• TMJ → pain, popping or crepitus

(pt. open/close mouth)

Neuro Test

• CN 7 (Facial - motor) → pt. smile, frown,

puff cheeks, resist eye opening

• CN 5 (Trigeminal - motor) → pt. clench jaw

– masseter muscle engaged

• CN 5 (Trigeminal - sensory) → light touch x6

(ask pt. close your eyes & say “now” when you

feel it)

“Pt is normocephalic – atraumatic”

NECK

Inspect

• Obvious masses or pulsations

Palpate

• Lymph nodes of head & neck; identify chains

o Preauricular, postauricular, occipital

o Tonsillar, submandibular, submental

o Anterior cervical, posterior cervical &

deep cervical (lean R/L)

o Supraclavicular, infraclavicular

o Non-palpable or <1cm, mobile, & non-

tender

• Carotids → pulses

• Trachea → deviation

• Thyroid → size, symmetry, tenderness,

consistency, nodules (palpate from behind)

Auscultate

• Carotid & Thyroid for bruit

Neuro Test

• CN 11 – Spinal Accessory (motor) → shrug

shoulders, turn head against resistance

“CN 2 – 12 are intact”

2 EYES → PERRLA & EOMI

Inspect

• External Inspection

o Eyelashes → point out & away

o Conjunctiva/sclerae/cornea → clear &

moist

o Pupil → size & shape

o (3-5mm b/l, round)

• 3 Finger Test

o Visual fields on confrontation

(CN 2 – Optic) (Jazz hands)

▪ Start laterally → Ask pt. stare

straight in front & let me know

when you see my fingers

o 6 cardinal fields of gaze (CN 3, 4, & 6 –

Oculomotor, Trochlear & Abducens)

(Cat Whiskers)

▪ Ask pt. follow my finger & not

move your head

o Accommodation & Convergence

(CN 2 & 3) (Follow Finger)

▪ Ask pt. to follow my finger as I

bring it closer to pt. face & away

• 2 Light Test (Pen light)

o Direct (CN 2) constrict & consensual

(CN 3) light reflexes, consensually

constricts

o Corneal light reflex → strabismus

(shine light & see that the light falls in the

same place in both eyes)

• 1 Ophthalmoscope Exam

(Right Eye to Right Eye)

o Catch red light reflex & move closer into

pt.

o Optic disc → clear, well defined, creamy

yellow

o 4 sets of retinal vessels

o Macula → 2 optic discs away

“Pt is PERRLA & EOMI - Pupils are equal,

round, reactive to light & accommodation ;

Extra ocular movements intact”

EARS

• Assess gross hearing

(CN 8 – Vestibular Cochlear)

o Normal conversation

o Whisper test/finger rub

o Ask pt. to close their eyes & point

to the ear where they hear the

finger rub

o If abnormal, continue to Weber

(midline) & Rinne (AC>BC) test

Inspect

• Auricle → symmetry, lesions, nodules

• Special attention to back & top of ears as it is

a common site for skin cancer

Palpate

• Tragus & mastoid → tenderness

Otoscopic Exam

• Maneuver Auricle

o Adults Pinna → up & back

o Peds Pinna→ down & back

• Inspect canals → cerumen (ear wax), foreign

bodies, inflammation, discharge

• Inspect TM & note presence of the

following/abnormalities

o Not bulging or retracted

o Pearly gray color

o Bony prominences

o Cone of light (R ‘ 5; L ‘ 7)

MOUTH & PHARYNX

3 Inspect

• Lips → swelling, color, lesions (ask pt. to

smile)

• Teeth & gums → dentition, swelling, color,

lesions (ask pt. to open mouth)

• Buccal mucosa → color, moisture, lesions

• Tongue → lesions, moisture, texture

o Pink, moist & well papillated

• Presence of Wharton (underneath tongue) &

Stenson ducts (upper 2nd molar)

• Posterior pharynx → color, exudate, lesions

o Non-red, non-injected

o Grade tonsils (1-4)

• Patency of salivary glands → parotid &

submandibular

Neuro Test

• CN 12 (Hypoglossal) → stick out tongue,

noting deviation

• CN 9 (Glossopharyngeal - motor/sensory) →

press down w/ tongue blade, ask pt. to say

“ah,” noting rise & position of uvula

• CN 10 (Vagus) → gag reflex

NOSE & SINUSES

• Assess nasal patency

o Ask pt. to occlude one nostril by pinching

down & breath in

Inspect

• Nose → midline

• Septum → deviated or perforated

• Nasal mucosa → color, exudate, swelling,

polyps

o Mucosa → moist, pink

o Turbinate’s → beefy red

Palpate

• Frontal & maxillary sinuses → tenderness

4 POSTERIOR LUNGS

Inspect

• RR & rhythm, overall effort (RR 12-20)

• General contour, spine midline

• Rib interspaces, accessory muscles

(are they using them?), no retractions

Palpate

• Respiratory expansion (thumbs rise and fall

equal bilaterally, note symmetric expansion of

hands)

• Tactile fremitus – feeling for vibrations

diminishing (4 spots) “99” (palmar surface)

Percuss

• Diaphragmatic excursion (3-5cm) bilaterally

o Ask pt. to breathes out → percuss from

resonance to dullness

o Ask pt. to breathes in → percuss from

resonance to dullness

o Flat = bone

o Dull = organ

• 7 spots: intercostal spaces (ICS) → resonance

• Percuss right middle lobe (RML)

Auscultate

• Lung fields: same 7 spots

(deep breaths in/out w/ open mouth)

o Assess right middle lobe (RML)

• Normal clear breath sounds are

o BV → superior medial

o V → peripheral lung

• Note adventitious breath sounds: wheezes,

crackles, pleural rubs, stridor

ANTERIOR LUNGS (in front of pt.)

Inspect

• RR & rhythm, overall effort

• General contour

• Rib interspaces, accessory muscles

(are they using them?), no retractions

• Transverse: Anterior-Posterior diameter

→(2:1)

Palpate

• Respiratory expansion (thumbs rise & fall

equal bilaterally, note symmetric expansion of

hands)

• Tactile fremitus – feeling for vibrations

diminishing (3 spots) “99” (palmar surface)

• Fluid = better sound of “99”

Percuss

• 6 spots: ICS → resonance

Auscultate

• Lung fields: same 6 spots

(deep breaths in/out w/ open mouth)

• Normal clear breath sounds (V, BV)

• Note adventitious breath sounds

5 Vitals Check Reminders

• Radial Pulse

o Bilaterally; note differences if any

• Blood Pressure

o Pt. should be at rest in a comfortable,

relaxed position, legs uncrossed

o Continue to fill air bladder 30mmHg

beyond the disappearance of sounds of

turbulent flow to account for the

auscultatory gap

CV NECK

Inspect

• Carotid/jugular pulsations, neck vein

distention (JVD)

Palpate

• Carotid pulse → bilaterally (one at a time)

Auscultate (Bell)

• Carotids → presence/absence of a bruit

• Instruct pt. to hold breath/hold breathe w/ pt.

CV CHEST

Inspect

• Precordium → heaves or lifts

Palpate

• Palmar surface of hand over;

o Auscultatory areas (see pics) → thrills

o Location of PMI

Auscultate

• Note murmurs, rubs or gallops

Diaphragm and Bell (sitting)

• Aortic (2 ICS RSB) → S2 > S1

• Pulmonic (2 ICS LSB) → S2 > S1

• Erb’s Point (3 ICS LSB) → S2 = S1

• Tricuspid (5 ICS LSB) → S1 > S2

• Mitral (5 ICS MCL) → S1 > S2

Bell in the left lateral decubitus position

(knees up on side)

• Mitral/Left ventricle (PMI)

Diaphragm while leaning forward

• Aortic & Pulmonic

6 ABDOMEN

*Inspect, Auscultate, Percuss, Palpation*

(4 quadrants, start at RLQ→ clockwise)

Inspect

• Stand on pts RIGHT side

• Patients arms by their sides, (not above their

head) lying down, knees bent → go to

bathroom if necessary

• Visualize skin-note, symmetry, scars,

masses, protuberance, distention, increased

or absent aortic pulsations, general size,

contour, shape

Auscultate

• Auscultate for bowel sounds → 4Q, 5-

30x/min (diaphragm)

• If absent, listen for 5 mins

• Auscultate for abdominal bruits

(aorta/renal/iliac/femoral) (bell)

“Bowel sounds are normal active in

all 4 quadrants”

Percuss

• Percuss all 4Q’s in a z-like pattern

o 2 spots/quad

• Identify areas of tympany & dullness

o Pay special attention to the flanks

for areas of dullness → tympany

to dullness

• Measure the vertical span of the liver

o From lower border:

▪ Tympany →dullness

o From upper border:

▪ Resonance → dullness

o 6-12 cm at MCL, 4-8 cm at MSL

• Percuss for splenomegaly

o L anterior axillary line, at lowest

intercostal space

o Percuss (tympanic) →have pt.

breath in →percuss (tympanic)

• Tympany to tympany

Palpate

• Light palpation (1 hand) in all 4 quadrants

o Notice any guarding, wincing,

rigidity, tenderness

• Deep palpation (2 hands) in all 4 quadrants

o Note underlying

structures/masses

• Palpate lower edge of liver

o Hold from back with one hand and

the other on the edge

o Under R costal margin, ask pt to

breathe in

o Soft, sharp, smooth, non-tender, no

nodules

• Palpate for splenomegaly

o Reach L hand around to

support/press L rib cage up, push R

hand in toward costal margin

o Ask pt. to take a deep breath,

palpate for tip of spleen deep to the

L costal margin

o Normal spleen not palpable (the tip

of the spleen)

• Palpate for kidneys using “capture

maneuver”

o Stand on R, ask pt to inhale - put R

hand above, L hand below to

“capture” kidney

o Ask patient to exhale/hold - slowly

release R hand to feel kidney

▪ Note size, contour,

tenderness

o Palpate L kidney on L side

o Palpate and estimate abdominal

aorta (<3cm)

o CVAT → ask pt. to sit upright

o Tap with hand/fist at CVA margin

bilaterally

o Ask pt. if they feel any pain

7 MUSCULOSKELETAL

Inspect

• Inspect spine for alignment

Palpate

• Palpate spine for tenderness

Range of Motion Test

• Assess for asymmetry, erythema, heat,

swelling, tenderness, masses, bogginess,

crepitus, and limitations in ROM

• DIP, PIP, MCP

• Wrist, elbows, shoulders ACTIVE

o For shoulder: elbow rests at side

• Knee, hips, legs

o Abduction, adduction

▪ Away/towards body

o Internal rotation, external rotation,

circumduction

o Leg: internal, external, flexion

o Ask pt to lie down now

• Ankles

o Inversion, eversion, plantar flexion,

dorsal flexion

• Toes

o Wiggle

o Abduct/adduct

• Neck

o L/R motion

o Circumduction

• Spine (while standing)

o Lean back, lean forward, rotate side

to side

o Place hands between pt for support

Muscle Strength Test

• Assess muscle strength against resistance

for shoulders, elbows, wrists, hand grips,

fingers, hips, knees, ankles

o Hints:

▪ Arms: parallel push/pull;

genie up/down

▪ Hand: spread fingers &

don’t let me close them;

squeeze my fingers as

hard as you can

• Cross fingers

here

▪ Hips: thighs push up

▪ Knees: shins push out,

pull back

▪ Feet: push up, push down

“Muscle strength graded at 5/5 conducted against

resistance”

Muscle Grading

5/5 = Good against resistance

4/5 = Less strength

3/5 = against gravity, not resistance

2/5 = contractions

1/5 = very limited

0/5 = flaccid

8

9 NEUROLOGICAL

Mental Status:

o A & O x 4 (person, place, time, situation)

Cranial Nerves:

o “CN 2 – 12 are intact”

Motor:

o “I am assessing for normal muscle bulk and

tone”

• ROM

o “ROM is intact”

• **Muscle strength**

o Perform (listed on previous page)

Sensory:

• Spinothalamic tract

o Perception of light touch

o Cotton ball on diff. dermatomes

▪ 5 different points

o Perception of pain (sharp/dull test)

▪ Show and state what a

sharp and dull touch is

o “The spinothalamic is intact”

• Posterior column tract (BILATERALLY)

o Vibratory sense

▪ Tuning fork on DIP of

thumb and big toe

▪ Hit fork and then stop

▪ Ask pt. to close eyes &

state when vibration stops

o Proprioception

▪ Demo first. Tell me if

thumb or big toe up/down

▪ Demonstrate what it looks

like first

▪ Use hands on the outside

of thumb of DIP

▪ Ask pt. to close eyes &

state up or down

o Graphesthesia

▪ Draw # in each hand – “3”

or “8”

▪ Ask pt. what # was drawn

o “The posterior column is intact”

Deep Tendon Reflexes

• Brachioradialis, biceps, triceps

o Measure 2 inches using hammer

o Hit your thumb & not pt.

• Patellar, achilles, plantar

o Ask pt. to lie down

o Plantar: Use the back of the

hammer to draw an “L” shape

• “I am grading all reflexes at a 2+”

Cerebellar Function

• Coordination and skilled movements

o Rapid alternating movements

(patty cake, peddle bike, finger to

thumb)

o Finger to nose (3 areas each b/l,

noting no tremors)

▪ Switch hands

o Heel to shin

• Romberg test (30 sec standing, eyes closed,

& feet together)

o Support hands

o + exam = swaying

• Pronator drift (30 sec standing, eyes

closed, arms out)

o Palms up

o Over/under compensation (tap

across both arms)

• Evaluate gait and general posture

o Ask pt. to walk 10 steps

10

11

12

Liver Span percussion

• Increased liver span on percussion indicates an

enlarged liver, which can underlie a variety of

pathological processes. It is essential to identify

both the lower and the upper borders of the liver

dullness to distinguish between an enlarged liver

(which has an increased span), and a liver

displaced downwards as a result of chronic

obstructive pulmonary disease (in which case the

liver span is normal).

1. Start by locating the right midclavicular

line. Lightly percuss in the right

midclavicular line upwards starting in the

area of tympany below the umbilicus.

Bending down to listen carefully to the

percussion note might be required.

2. Make a mark where the tympany changes

to dullness (lower border) with a skin

pencil.

3. Percuss in the right midclavicular line

downwards starting at the nipple line to

identify an upper border of liver dullness.

4. Mark the point on the abdominal wall

where the resonant sound over the lungs

changes to dullness over the liver with a

skin pencil.

5. Measure the distance between upper and

lower border of dullness in cm. Liver span

depends on age, sex, and body type. The

liver span is normally 6-12 cm (mean liver

span is 7 cm for women and 10.5 cm for

men).

6. If the liver span is increased, percuss

laterally and medially. Normal liver span

in the midsternal line is 4-8 cm.

Spleen percussion

• The spleen is located slightly posterior to

the left midaxillary line and produces an

oval area of dullness between the 9th

and

11th

ribs. Only a small surface of a normal

spleen is superficial enough to be

detected, and the splenic dullness is often

obscured by gastric or colonic tympany.

However, an enlarged spleen is expanded

towards the midline, anteriorly, and

downward, and might be detected by two

special percussion maneuvers: Traube's

space percussion and/or Castell's

maneuver.

• Percussion of Traube's space, anterior

axillary line, and left costal margin.

• Along with the other pathological

conditions medial expansion of

an enlarged spleen can produce

dullness on percussion over

Traube's space.

• With the patient supine and their

left arm slightly abducted,

percuss from the medial to lateral

border of Traube's space.

Dullness on percussion or

reduction of the area of tympany

can result from splenomegaly.

• Castell's method (checking for a splenic

percussion sign).

• Percuss in the anterior axillary

line in the lower intercostal space.

• Ask the patient to take a deep

breath, and percuss again. A

normal-sized spleen is positioned

above the percussion point even

when it descends during

inspiration, and the percussion

tone is tympanic on both

expiration and inspiration.

• If percussion note is dull or becomes dull

on inspiration (positive splenic percussion

sign), splenomegaly is suspected

Capture Maneuver-kidney palpation

• Start with the right side and place one

hand under the patient's right flank and the

other hand at the right costal margin.

• Instruct patient to take a deep breath and

at the height of inspiration press the

fingers of both hands together to try to

capture the kidney then have

• patient exhale and hold

• Slowly release the pressure and feel for

the kidney to slide between your fingers-

it may not be palpable

• Try to capture the left kidney –the left

kidney is less likely to be palpable If the

kidneys are palpable they should be

smooth firm and non-tender

13 Abbreviations & Definitions

A & O = alert and oriented

Apnea = temporary cessation of breathing

Avg. = average

b/l = bilaterally

BV = bronchovesicular lung sounds

CN = cranial nerve

Crackles = rales, foil rubbing together, rattling sound

CVAT = costal vertebral angle tenderness

DIP = distal interphalangeal joint

Dull = soft, muffled sound, organs

Dyspnea = difficulty breathing

EOMI = extra ocular movements intact

Flat = soft, high-pitched sound, bone

GI = gastrointestinal

Heave = heart beating out of chest

Hyperpnea = extremely deep breathing

Hyperresonance = overinflated lung, lower-pitched

Hyperventilation = extremely rapid breathing

Hypoventilation = extremely slow breathing

ICS = intercostal spaces

Ident. = identity

Kussmaul’s = marked increase in depth & rate

LSB = left sternal boarder

MCL = midclavicular line

MSL = midsternal line

mm = millimeters

NAD = no acute distress

NCAT = normocephalic – atraumatic

Orthopnea = body must be upright to breathe

Paradoxical = one lung deflates during inhalation

PERRLA = pupils are equal, round, reactive to light

& accommodation

PIP = proximal interphalangeal joint

PMI = point of maximum impulse

Pt = patient

Q = quadrants

Rales = small clicking, bubbling

Rhonchi = low-pitches snoring sound

Resonance = normal breath sounds

RR = respiratory rate

RSB = right sternal boarder

S1 = “lub” closing of AV tricuspid and mitral valve,

dull & low-pitched

S2 = “dub” closing SA pulmonic and aortic valve

Stridor = high pitch wheezing

Thrills = vibrations like cat purring

TMJ = temporomandibular joint

Tympani = loud, drum-like sound found in air-filled

viscera

V = vesicular lung sounds

w/ = with

Wheeze = high-pitched sound by narrow airway

WNL = within normal limit

y/o = years old

# = Number

& = and

PULSES: Peripheral pulses should be

compared for rate, rhythm &

quality

0 Absent

+1 Weak & thready

+2 Normal

+3 Full

+4 Bounding

EDEMA: Assess by placing thumb over

dorsum of the foot or tibia for

5 seconds

0 No edema

+1 Barely discernible depression

+2 A deeper depression (<5mm)

w/ normal foot & leg contours

+3 Deep depression (5-10mm) w/

foot & leg swelling

+4 Deeper depression (>1cm) w/

sever foot & leg swelling