Physical examination of the patient

this document includes all the essential headings under which physical examination of the patient is done. it helps in collecting the objective information from the patient

1. Physical examination
Identification data of the patient
 Patient’s name:-
 Age:-
 Gender:-
 Hospital name:-
 File no./ MLC no.:-
 Source providing history:-
 Date and time of admission:-
 OPD No.:-
 IPD No.:-
 Ward:-
 Bed no:-.
 Provisional diagnosis:-
 Surgery done/ Date of surgery:-
 Name of surgery:-
 Residential address:-
 Mother tongue:-
 Marital status:-
 Educational status:-
 Occupation:-
 Monthly income:-

General appearance
 Body type:-
 Posture:-
 Gait:-
 Activity:-

Vital signs

 Temperature:-
 Pulse:-
 Respiration:-
 Blood pressure:-

Height and weight

INTEGUMENT
Skin:
 Colour:-
 Moisture:-
 Temperature:-
 Texture:-

2.  Turgor:-
 Vascularity:-
 Lesions:-

Hair and scalp:
 Distribution:-
 Colour:-
 Appearance:-
 Scalp:-
 Hair follicles:-

Nails:
 Color:-
 Thickness:-
 Shape:-

HEAD AND NECK

Head:

 Position:-

Eyes:
 Position and alignment:-
 Eyebrows:-
 Eyelids:-
 Lacrimal ducts:-
 Conjunctiva:-
 Sclera:-
 Cornea:-
 Pupil:-
 Lens:-
 Visual acuity:-

Ears:

 Auricles:-
 Ear drum:-
 Hearing acquity:-

Nose:

3.  External nares:-
 Mucosa:-
 Discharge:-
 Nasal septum:-
 Sinuses:-

Mouth and pharynx:

 Lips:-
 Mucosa:-
 Gums:-
 Teeth:-
 Tongue:-
 Palate:-
 Pharynx:-

Neck:

 Neck muscles:-
 Lymph nodes:-
 Thyroid gland:-
 Trachea:-

THORAX AND LUNGS

Posterior thorax:

 Contour:-
 Intercostal spaces:-
 Rhythm of breathing:-
 Thoracic muscles:-
 Fremitus:-
 Percussion:-
 Auscultation:-

Anterior thorax:

 Thoracic muscles:-
 Fremitus:-
 Percussion:-

4.  Auscultation:-

Lateral thorax:
 Percussion:-

HEART

 Inspection:-
 Palpation:-
 Auscultation:-
 Heart rate:-

BREAST

 Inspection:-
 Nipple:-
 Palpation:-

ABDOMEN

 Inspection:-
 Palpation:-
 Percussion:-
 Auscultation:-

GENITALIA (Female)

 Labia majora:-
 Labia minora:-
 Urethral orifice:-
 Vaginal orifice:-

GENITALIA (Male)

 Penis:-
 Scrotum:-
 Inguinal ring and canal:-

RECTUM AND ANUS

5.  Inspection:-
 Digital palpation:-

MUSCULOSKELETAL SYSTEM

 Inspection:-
 Palpation:-
 Range of motion:-
 Muscle tone and strength:-

NEUROLOGICAL SYSTEM

 Level of consciousness:-
 Behavior:-
 Cranial nerve function:-

Reflexes:
 Biceps:-
 Triceps:-
 Patellar:-
 Achilles:-
 Plantar:-
 Gluteal:-
 Abdominal:-