PHYSICAL EXAMINATION
GENERAL OBSERVATION
Constitution : Ectomorphic
Stature : Normal
stature
Posture : Normal posture, no deformity, normal
gait
Personal appearance : Neat and tidy.
Emotional status : Anxious and depressed.
Co-operativeness : Co-operative
VITAL SIGNS
Temperature : 98.60 F
Pulse ` : 88 b/mt
Respiration : 26 br/mt
BP : 130/90 mm of Hg
HEIGHT AND WEIGHT
Height : 45 Kg
Weight : 160 cms
SKIN AND MUCOUS MEMBRANE
Colour of the skin : Pallor is present, no lesions or
cracks.
Edema : Absent
Moisture and turgor : Skin is less moist.
HEAD
Shape : Normocephalic, no lesions tenderness,
hair colour
and distribution are normal, hair is brittle,
no dandruff or lice.
EYES
EXPRESSIONS : Normal , no discharge
Eyelids : No edema, no blepheritis.
Eyeball : Normal
and clear.
Conjunctiva : Pale
Sclera : Creamy white in colour, no
discolouration.
Iris : Black in colour.
Visual acuity : Normal
Pupils PERRLA : Normal, symmetrical and normal pupil
Constriction
(3mm)
Eye movements : In conjugate fashion.
EARS
Appearance : Auricles are symmetric, wax is present.
Hearing : Normal
NOSE
Appearance : No deviation of nasal septum or nasal flaring,
mucous membrane is pale.
MOUTH AND THROAT
Lips : Dry, no cracks
Tongue : No glossitis, reddish in colour.
Teeth : Not stained, no missing teeth
Gum : No bleeding or gingivitis.
Buccal mucossa : No stomatitis
Palate : Intact, no deformity.
Taste : Normal
sensation of taste.
NECK
Appearance : No deformity, or stiffness.
Trachea : Centrally located
Lymph node : Not palpable.
Thyroid gland : Not enlarged
CHEST AND RESPIRATORY SYSTEM
INSPECTION
Symmetry : Bilaterally symmetrical
Expansion : Equal
Equality of movement : Normal
Type of respiration : Abdominothoracic
Rate
Rhythm : Normal
PALPATION
PALPATION
Expansion : Normal
Local Swelling : Absent
Vocal Tactile fremitus : Normal
PERCUSSION
Basal :
Apical : Normal
Axillaries of mid zone : Normal
AUSCULATION
Bronchial breath sounds : Normal , high pitched and
clear.
Broncho vesicular sounds : Clear and relatively low pitched.
Vesicular
sounds
: Normal and low pitched
CARDIO VASCULAR SYSTEM
INSPECTION
Chest contour : Normal, no sternal depression
Pericardium : Normal, no bulging
Neck : Normal ,
no jugular venous distention.
PALPATION
Pericardium : No thrill
Neck : Arterial pulsation is present.
Supra sternal
notch : No thrill
PERCUSSION
Cardiac outline : Difficult to find the cardiac border.
AUSCULTATION
Apical rate : S1, S2 heard, no murmur.
BP : 130/90 mm of Hg
Neck : No carotid bruits or murmurs
ABDOMEN
INSPECTION
Shape : Normal ,
scaphoid shape
Movements : Normal, abdominal wall bulges during inspiration and falls on
expiration.
Skin texture : Normal ,
decreased skin turgor, no cyanosis or
lesions.
Contour : Normal
flat, no mass
PALPATION
Mass : Absent
PERCUSSION : No fluid or gas collection
AUSCULTATION :
BACK
Spinal curvature : No deformity, concavity in cervical
lumbar region
and convexity in the thorax.
Symmetry : Normal
Movement and mobility : Normal movements
Tenderness : Absent
GENITALIA : Nothing significant.
UPPER AND LOWER EXTREMITIES
Upper extremities : Normal
ROM, no deformities.
Lower extremities : Normal
ROM, no deformities.
NERVOUS FUNCTION
Higher function : Normal
Speech : Clear and fluent
Cranial nerves : Normal .
Motor function : Normal ,
good muscle tone.
Sensory function : Normal ,
responds to pain and touch.
Reflexes : Normal
