PHYSICAL ASSESSMENT PROCEDURE

1 2 3 4 5
SKIN
1. WASH HANDS
2. Take TPR, BP, height and weight
3. Skin: color, pigmentation, lesions, jaundice,
cyanosis, scars, vascularity, moisture, edema,
color of mucous membrane, hair distribution,
nails
4. Palpate skin for temperature, texture,
elasticity, turgor
5. Head: inspect the symmetry, configuration of
skull, hair scalp.
6. Palpate hair Texture, Masses, swelling
tenderness of scalp, configuration of skull.
EYES AND VISION
7. Inspect globes, palpebral fissures, lid margins,
conjunctiva, sclera, pupils, eye movement,
visual acuity(use Snellen’s Chart)
8. Palpate upper lids and globes
9. Fundoscopic examination. PERRLA
EAR AND HEARING
10. Use Otoscope, Hold helix, gently pull pinna
upward and backward toward the occiput
11.Gently insert otoscope, examine the ear
12.Inspect Pinna, External canal, tympanic
membrane, landmarks
13.Palpate pinna for tenderness, consistency of
cartilage, swelling
14.Mechanical test PRN: Weber and Rinne Test
NOSE AND SINUSES
15. Insect for general deformity
16.With nasal speculum examine: nasal septum,
discharge, obstructions, mucus membrane
color, turbinate for color and swelling.
17.Palpate sinuses for tenderness
MOUTH
18. Inspect the lips for color and moisture,
pigment, masses, ulceration and fissures.
19.Using tongue depressor and penlight,
examine, teeth, gums, buccal mucosa,
pharynx, tongue, salivary gland, uvula, tonsils,
odor for breath and voice.
20.Record.
NECK
21. Inspect for symmetry, masses and unusual
swelling, pulsation’s, ROM
22.Thyroid: ask the patient to swallow.
23.Muscular strength of cervical muscles and
 trapezius muscle.
24.Examine external jugular veins
25.Palpet cervical nodes, salivary glands, trachea,
thyroid, and carotid arteries.
LYMPH NODES
26. Inspect for size, shape, mobility, consistency,
tenderness, and inflammation
27.Palpate cervical supra and infraclavicular
node, axillary nodes, inguinal nodes,
epithochlear nodes
BREAST
28. Inspect for Areola and nipples for position,
pigmentation, inversion, discharge, crusting
and masses.
29.Examine breast tissue for size, shape color,
symmetry, surface, contour, skin
characteristic, level, retraction or dimpling. *
start with asymptomatic side
30.Palpate with pillows under scapulae at arms
raised.
31.Palpate one breast at a time using the palmar
surface in rotating motion, compressing tissue
against chest wall.
32.Note skin texture, moisture, temperature and
masses
33.Gently squeeze the nipple and note discharge
34.Repeat examination of opposite breast and
compare findings.
THORAX AND LUNGS
35. Have the patient seated; examine posterior
chest and lungs.
36.Inspect spine for mobility, deformities
37.Observe for symmetry, posture and mobility of
thorax upon respiration
38.Palpate posterior chest with patient sitting;
identify area of tenderness masses,
inflammation
39.Palpate the rib, costal margins for symmetry,
mobility and tenderness and the spine for
tenderness.
40.To assess respiratory excursion, place the
thumb at the levels of the 10th vertebrae with
the hand parallel to the 10th rib, then ask
patient to inhale deeply. Observe movement.
41.To vocal and tactile/fremitus: ask the patient
to say “99” and use ball of one hand.

ABDOMEN
42.Let patient empty bladder.
43.Observe general contour of abdomen,
 symmetry, visible peristalsis and aortic
pulsation
44.Check umbilicus for conour and hernia and the
skin for rashes, striae, and scars
45.Auscultate and note the frequency and
characters of bowel sounds(pitch, Duration)
46.Listen over the aorta an renal arteries for
bruits
MALE GENETALIA
47. Inspect the pubic hair distribution and the
skin of the penis
48.Retract or have the patient retract the
foreskin, if present
49.Observe the glans penis and the urethral
meatus. Note any ulcers, masses and scars.
50.Note the location of the urethral meatus and
any discharge
51.Observe the skin of the scrotum for ulcers,
masses, redness, or swelling. Note the size,
contour and symmetry. Palpate for presence
of masses.
52.Inspect the inguinal areas and the groin for
bulges. Palpate for inguinal hernias.
FEMALE GENITALIA
53. Let the patient empty their bladder. Place in
lithotomy position
54.Inspect the pubic hair distribution, the labia
majora, the monspubis and the perineum
55.With gloved hand, separet e the labia majora
and inspect the clitoris , urethral meatus and
vaginal opening. Note the skin color,
ulcerations, nodules, discharge and swelling.
RECTUM
56. Have the patient stand and bend over the
edge of the table
57.Spread buttocks and inspect the anus,
perianal region, and sacral region for
inflammation, nodules, scars, lesions,
ulcerations and rashes.
58.Palpate any abnormal area noted on
inspection
LOWER EXTREMITIES
59.Observe skin over extremities for color, pallor,
rubor, and hair distribution
60.Inspect for any superficial vessels
61.Note temperature of the skin over extremities,
comparing one side to the other.
62.Palpate pulses(radial, femoral, posterior tibial,
dorsalis pedis) comparing symmetry for side
to side
63.Palpate the skin over the tibia for edema and
note for indention

TOTAL
ABILITY TO ANSWER QUESTIONS: