PHYSICAL

EXAMINATION
Presenter: -
Amit Mann
[Link]. Nursing 1st Yr
College of Nursing
AIIMS, DELHI
In this session we are going to cover the assessment of the
following systems :
• 1. Cardiovascular system
• 2. Gastrointestinal system
• 3. Musculoskeletal system
• 4. Neurological system
Cardio vascular system
Inspection
• Look for the previous scar
Palpation
Percussion
Auscultation
Auscultation
Normal S1 & S2
heart murmur caused by mitral
valve regurgitation
S3 heart sound
S4 heart sound
Pericardial friction rub
 vascular system

Inspection
• Start by making general observations.
• Are the arms equal in size? Are the legs
symmetrical?
• clubbing, and edema of the extremities.
• Palpation
• First, assess skin temperature, texture, and
turgor.
• Then assess capillary refill
Cyanosis
PALLOR
Edema
Anascara
Grading of edema
Venous insufficiency Arterial insufficiency
ABDOMINAL ASSESSMENT
ABDOMINAL ASSESSMENT
Abdominal Exam:
Basics
• Patient should be lying flat
• Abdomen should be fully exposed
• Arms at side (behind head tightens
abdomen) & legs straight
• Bending knees may relax abdomen
• Sheet over the genitals
Order of Examination
• Inspection
• Auscultation
• Percussion
• Palpation
Inspection
■ Examine the patient in good light and warm surroundings.

■ Position the patient comfortably supine with the head resting

on only one or two pillows to relax the abdominal wall muscles.

■ Use extra pillows to support a patient with kyphosis or

breathlessness.

■ Expose the abdomen from the xiphisternum to the symphysis

pubis, leaving the chest and legs covered.
Inspection: abdomen

1. Abdominal contour- Flat or distended

2. Dilated veins
3. Skin color, scar mark, suture mark
4. Umbilicus
5. Hernial orifices
6. Observe for pulsation
7. Peristalsis movement
8. Respiratory movement
Normal findings

• The abdomen is normally flat or slightly

scaphoid and symmetrical.
• Abdominal girth – <94cm in men and
<80cm in women
 Surgery scar
Abnormal findings

Grey Turner sign

Cullen’s sign
Striae Caput Medusa

Spider
Auscultation
 Provides important information about bowel motility:
decreased motility suggests peritonitis; increased motility
suggests obstruction

 Need to listen before percussion or palpation since these

maneuvers may alter the frequency of bowel sounds

 Can also appreciate bruits over the aorta or other arteries,

suggesting narrowing of the arteries from atherosclerosis
Auscultation for Bowel sounds:
• Normal intestinal propulsion of
food (peristalsis) generates noise
(Borborygmi)

• Listen (diaphragm of stethoscope)

x 15-20 seconds in 4 quadrants

• Pay attention to: presence,

quantity (normal ~ 2-5 seconds), &
quality of sounds
Bruits - Bruits are high pitched sounds
due to obstruction to flow due to
narrowing (stenosis) of arteries
• Listen over:
• Renal arteries
(several cm above umbilicus,
either side of rectus)
• Iliac arteries (below
umbilicus)
• Aorta (Listen midline)
 PERCUSSION

• Percussion detects:
i. Gas
ii. Fluid e.g. ascites, urinary bladder
iii. Organs as confirmation of palpation.

• Light or heavy percussion ??

Light percussion should only be used

• Direct vs Indirect

• When to do???
After auscultation
Cont..
There are two basic sounds which
can be elicited:

• Tympanic (drum-like) sounds

If percussion
produced by percussing over air produces pain,
filled structures. as in peritonitis.
This would
• Dull sounds that occur when a certainly be
solid structure (e.g. liver) or fluid supported by
(e.g. ascites) lies beneath the other historical
region being examined.
and exam
findings.
Percuss in all the
four quadrants,
starting from
right lower
quadrant
proceeding to the
left lower
quadrant
LIVER
 SPLEEN
• patient in the supine position. Percuss the lowest intercostal space
[8th or 9th] in the anterior axillary line.

• Ask patient to take strong inspiration during percussion, if dull

=splenomegaly
 PALPATION

• Warm your hands and assess temperature.

• Tenderness - Guarding
• Most important structures aren’t palpable
• Generally right hand used (left placed on
top or at your side)
• Palpate using pads & edges of middle 3
fingers
• Gentle pressure, no sudden movements
 Palpation Technique
• First explore superficial aspect each quadrant
(start R lower R upper L upper L lower).

Deep palpation of liver

Classical Method Hook Method
 Palpation Technique
Spleen Bimanual method
Classical Method

Hook method
PALPATION OF KIDNEY

Bimanual method

Right kidney Left kidney

 Obturator’ sign

Psoas sign
• Press on the left lower
quadrant of the abdomen and
then release pressure.
• If the patient feels pain in the
right lower quadrant when the
pressure is released, the test is
positive.
• Positive in appendicitis. Rovsing's sign
Fluid thrill test for ascites
ASSESSMENT OF THE MUSCULOSKELETAL
SYSTEM
(1)Inspection: For a comprehensive assessment, inspection
should be carried out observing from anterior, posterior and
lateral views. Inspection should assess for:
a) Shape: size , contour ,symmetry (Alike on both sides)
b) Structure: Normal or deviated from normal
(Deformities,fracture…)
• muscle configuration: hypertrophy/atrophy (steroid use,
malnutrition)
• body build , posture and body alignment : (Standing ,Sitting
and recumbent)
Bones Examine for:
1- Deformity

2- Tumors

3- Pain: is the pain focal

(fracture/trauma,infection, malignancy,
Paget’s disease,osteoid osteoma), or
diffuse (malignancy,
Paget’s disease, osteomalacia,
osteoporosis,metabolic bone disease)?
Evaluating the
temporomandibular joint
• Place the tips of your index fingers
in front of the middle of each ear,
as shown at right.
• Ask the patient to open and close
his mouth then move jaw side to
side.
 Assessing neck range of motion

• Ask the patient to try touching

his right ear to his right shoulder
and his left ear to his left
shoulder.
• The usual range of motion is 40
degrees on each side
■ Ask him to touch his chin to his
chest and then to point his chin
toward the ceiling.
• The neck should flex forward 45
degrees and extend Backward 55
degrees.
Assessing shoulder and elbow
range of motion
Assessing shoulder and elbow
range of motion
Assessing wrist range of motion
Assessing hip range of motion
Assessing ankle and foot range
of motion
Assessing patient shoulder
strength

• Test the strength of the patient’s

shoulder girdle by asking him to
extend his arms with the palms
up and hold this position for 30
seconds.
Testing upper extremity muscle
strength
Testing lower extremity muscle
strength
Testing lower extremity muscle
strength
Testing handgrip strength
• Face the patient.
• Extend the first and second
fingers of each hand, and ask
him to grasp your fingers and
squeeze.
Abnormal findings
Gower’s sign
Limb measurement
limbs are in the neutral
position.
• The patient is lying straight
• Full length upper limb –
measure from the acromion
process to the end of the
middle finger.
• Full length lower limb – lower
edge of the ileum to tibial
malleolus.
Special Tests
Phalen’s Test –Ask the
patient to hold the wrist in
acute flexion for 60 seconds.
Numbness or burning
indicate carpel tunnel
syndrome.
 Tinel’s sign

■ Lightly percuss the transverse carpal

ligament over the median nerve here the
patient’s palm and wrist meet.
■ If this action produces numbness and
tingling shooting into the palm and finger,
the patient has Tinel’s sign and may have
carpal tunnel syndrome.
NEUROLOGICAL EXAMINATION
Tools for Neurological
Examination
 Components of neurological
examination

CRANIAL SENSORY
HISTORY
NERVES SYSTEM

MOTOR
REFLEXES CEREBELLAR
SYSTEM
 Glasgow coma scale
CATEGORY RESPONSE SCORE
EYE OPENING Spontaneous 4
To speech 3
To pain 2
None 1

VERBAL RESPONSE Oriented 5

Confused 4
Inappropriate words 3

Incomprehensible sounds 2

None 1
SITES OF PAIN STIMULATION
Glasgow coma scale
CATEGORY RESPONSE SCORE
BEST MOTOR Obeys command 6
RESPONSE
Localizes pain 5
Withdraws from 4
pain
Abnormal flexion 3
Extension 2
None 1
TOTAL SCORE 15
 Interpretation of GCS
• On the basis of scores of Glasgow coma scale, coma
can be:
• Severe - with GCS ≤ 8

• Moderate - GCS 9 – 12

• Minor - GCS ≥ 13
 Cranial Nerves
[Link] Nerve (sensory)
Tested by the use of a variety of odoriferous substances like coffee, mint
cloves, lemon extract or vinegar with each nostril separately and with the
eyes closed.

[Link] Nerve (sensory)

Tested by measuring visual acuity and visual fields and inspecting the retina
and optic disc.

• Normal pupils are equal in size and shape and are situated in center of iris

• – Anisocoria = pupillary asymmetry

 Cranial Nerves

III. Oculomotor nerve (motor)

IV. Trochlear nerve(motor)
VI. Abducens nerve (motor)

• Assessment of Pupillary reflexes.

• Check the extra ocular movements in the six
cardinal directions of the gaze by asking the
patient to follow the moving finger.
• Eyelids should be symmetrical and it should not
obscure the pupil.
Cranial Nerves

(LR6SO4)3
 Cranial Nerves
V. Trigeminal nerve(Sensory and motor)
Largest cranial nerve
• Sensory portion-ophthalmic branch,
maxillary branch, mandibular branch.
• Assessed by evaluating touch, pain, and
temperature in all three branches and
comparing both sides of face.
• Corneal reflex also is tested.
 Cranial Nerves
Testing the motor component of trigeminal nerve
• Ask the patient to clench his teeth while you palpate the temporal
and masseter muscles.
• Note the strength of the muscle contraction; it should be equal
bilaterally.
 Cranial Nerves
VII. Facial Nerve (motor and sensory)
o Sensory part
-sense of taste from anterior 2/3rd of tongue,
-sensation from external ear
-parasympathetic fibers to the salivary glands, lacrimal glands
and nasal cavity
 Cranial Nerves
• Assessed by
-Asking the client to close the eyes and protrude the tongue.
-Then place a taste substance on one side of the anterior tongue.
Have the client keep the tongue protruded while identifying the taste.
-Ask the client to rinse the mouth or drink a small amount of water
before testing the other side.
 Cranial Nerves
o Motor part
• Supplies the muscles face and control facial expressions.
• Tests by asking the patient to raise the eyebrows, wrinkle the
forehead, close the eyes tightly, purse the lips, whistle, show the
teeth, blow out the cheeks and look up at the ceiling.
Cranial Nerves

VIII. Vestibulocochlear or Acoustic

nerve (sensory with two
divisions –auditory/cochlear
division and vestibular division)
Cochlear -Rinne’s test and Weber
test

Vestibular –Romberg’s test

 Cranial Nerves
IX. Glossopharyngeal nerve (motor and sensory)
Sensory part provides taste over posterior 1/3rd of tongue plus
pain, touch and temperature of the palate and pharynx.
Motor part
• To elicit gag reflex ,touch soft palate or posterior pharynx with a
cotton tipped applicator and watch elevation of palate, retraction of
tongue and contraction of pharyngeal muscles.
• Motor part: muscles of swallowing
 Cranial Nerves
X. Vagus Nerve (motor and sensory)
Supplied to pharynx and larynx and is essential
for swallow, phonation cough and gag.
Motor portion supplies muscles of swallowing.
-Ask the client to open the mouth widely and say
“Ah”. Observe the position and movement of uvula and
palate. The palate should rise symmetrically with uvula
at the midline.
 Cranial Nerves
XI. Spinal accessory Nerve(motor)
Assess the spinal accessory nerve by testing the
strength of the sternocleidomastoid muscles
and the upper portion of the trapezius muscle.
■ Place your palm against the patient’s cheek.
■ Ask the patient to turn his head against your
resistance.
■ Place your hands on the patient’s shoulder
and ask him to shrug his shoulders against your
resistance.
■ Repeat each test on the other side, comparing
muscle strength.
 Cranial Nerves

XII. Hypoglossal nerve(motor)

• Supplies to the muscles of

tongue.
• Deviation or tremors of the
tongue are noted when he
protrudes
 Sensory function

• Superficial sensation • Deep sensation

-Light touch -Vibration
-Superficial pain -Proprioception
-Skin temperature -Joint position sense
-Two point discrimination
-Steriognosis
-Graphesthesia
 Sensory function
• Light touch: Stroking a wisp of cotton on the patients skin while
avoiding pressure or depressing the skin.
• Both sides of the body are tested.
• Ask the patient to state where the sensation is felt and is it same on
both sides.
• A scale of 1-10 may be used.
 Sensory function
• Superficial pain :Assessed by the use of a light pinprick on the skin.

• Skin temperature: Assessed with test tubes of hot and cold water
applied in a random manner.
 Sensory function
• Vibration: Place the stem of a vibrating tuning fork on
a distal bony prominence, such as a finger or great toe
point.

• Proprioception: Assessed by asking the patient to

close both eyes and identify whether the thumb or
great toe is flexed or extended as it is manipulated
through the movements by the examiner.
 Sensory function

• Joint position sense: Tested by the use of passive

movement.
• With the eyes open patient is given a demonstration.
• With the eyes closed ,the patient is asked to indicate
which way the joint was moved.
 Sensory function
• Two point discrimination: Ability to distinguish the
separation of two simultaneous pinpricks.

• Stereognosis: Ability to distinguish common objects

placed in the hand when eyes are closed.

• Graphesthesia: Ability to distinguish numbers or

letters traced on the skin.
 Reflexes
• A reflex action is an involuntary function or movement in response to
a particular stimuli occuring immediately without the involvement of
will or consciousness.
3 common types:

-superficial reflex
-deep tendon/muscle stretch reflex
-pathologic reflex
 Superficial reflexes
Reflex Stimulus Response

Touch cornea with a wisp Prompt closure of both

Corneal of cotton eyelids

Pharyngeal Pharyngeal stimulation Gagging response

Abdominal Stroke upper or lower Contraction of abdominal

abdomen muscles with a brief, brisk
movement of umbilicus
towards stimulus

Plantar Stimulation of sole of foot Flexion of toes

 Corneal reflex

Plantar
reflex
 Reflexes
Deep tendon reflexes
Reflex Stimulus Response

Biceps Tap biceps tendon Contraction of biceps

Brachioradialis Tap styoid process of Flexion of elbow and

(periosteradial) radius (insertion of supination of forearm
brachioradialis)

Patellar(Knee jerk) Tap patellar tendon Extension of leg at knee

 Reflexes contd…
Reflex Stimulus Response

Triceps Tap triceps tendon Extension of elbow

Tendocalcaneus Tap Achilles tendon Plantar flexion at ankle

 Biceps reflex
testing

Triceps reflex
testing
 Brachioradialis
reflex testing

Patellar
reflex
testing
Pathologic reflex
• Caused by any lesion or organic disease of nervous system.
o Babinski’s sign - Dorsiflexion of the big toe with extension
and fanning of the other toes elicited by firmly stroking the
lateral aspect of the sole of foot.
 Cerebellar function
• Primary responsibilty of cerebellum is the integration of motor
functions such as muscle coordination, maintanance of equillibrium
and muscle tone.
 Assessment of motor function
1. Romberg’s test
■ Observe the patient’s balance as he
stands with his eyes open, feet together,
and arms at his sides.
■ Ask him to close his eyes.
■ Hold your arms out on either side of him
to protect him if he sways.
■ If he falls to one side, the result of
Romberg’s test is positive.
Assessment of motor function
2. HEEL-TOE WALKING
• Ask the client to walk a straight
line, placing the heel of one foot
directly in front of the toes of
the other foot.
• Normal findings :- Maintains
heel-toe walking along a straight
line
• Abnormal findings :- Assumes a
wider foot gait to stay upright.
 Assessment of motor function
STANDING ON ONE FOOT WITH EYES CLOSED

Ask the client to close the eyes and stand on one foot. Repeat on the
other foot. Stand close to the client during this test.

Normal findings :- Maintains stance for at least 5 seconds.

Abnormal findings :- Cannot maintain stance for 5 seconds.
Abnormal gaits
 Fine Motor Tests for the Upper Extremities

1 2

3 4
 Fine Motor Tests for the Lower
Extremities
1 2
Nurse’s responsibility

Explain the procedure and its need

Preparation of the environment
-Privacy
-Adequate lighting and ventilation
-Calm and quiet environment
Preparation of patient
-Physical
-Psychological
Preparation of articles
 Contd…..
• Nurse should be with the patient if a male examiner
examines a female patient

• Label the specimen if any and send it to lab

• Record the findings

• Inform the physician about the abnormal findings

Summary
Conclusion
“Nurses are most often the first person to
detect changes in client’s condition. The skills of
physical assessment and examination provides nurse a
powerful tool to detect suitable as well as obvious
changes in clients health.”