Physical Diagnosis

Introduction

The order described below allows the patient to be examined while changing position only three times (sitting, lying inclined, lying supine, and standing)

Sitting

General Appearance – developed/nourished/hydrated, emotional state

Vital signs – pulse (radial/brachial arteries) and blood pressure (lying and standing); respiration rate

Mental Status – orientation, short-term memory, calculation ability, speech/language, abstract reasoning

Skin – color, moisture, temperature, texture, mobility, turgor, lesions (location/arrangement/color)

hair: quantity, distribution, texture

Head and Neck (HEENT)

H (head):

inspect: symmetry, circumference, fontanelles, masses, hair loss

palpate: for tenderness, fontanelles

E (eyes):

test: visual acuity, visual fields (CN II)

inspect: position, alignment, eyebrows, eyelids, lacrimal apparatus, conjuctiva/sclera, cornea/iris/lens

examine pupils: size, shape, symmetry, reaction to light, near reaction

EOM: corneal reflections from midline light, six directions of gaze (follow H pattern), convergence (CN III/IV/VI)

ophthalmoscope: red reflex, optic disc, arteries/veins/AV crossings, retina, macula, anterior structures

E (ears):

inspect: auricle (move and push tragus (OE), press behind (OM)); palpate mastoid process

otoscope: pull auricle, inspect canal, eardrum

hearing: acuity (whispered/spoken voice), Weber/Rinne (CN VIII)

N (nose)

inspect: external nose, internal nares, septum

palpate: frontal and maxillary sinuses

T (throat)

inspect: lips, oral mucosa, gums, teeth, roof of mouth, tongue (papillae/symmetry/lesions), floor of mouth, pharynx (exudate/tonsils/soft palate symmetry with ah) (CN IX/X)

test: tongue motion (CN XII), gag reflex (CN IX/X)

Neck:

inspect: neck, position of trachea

palpate: lymph nodes: occipital, anterior and posterior cervical, submandibular, supraclavicular

inspect thyroid: at rest, swollowing

Cranial Nerves: all but three have already been tested

V – jaw close (temporal/masseter); corneal reflex
VII – raise eyebrows, frown, close eyes tightly, show teeth, smile, puff out cheeks
XI – shoulder shrug; move neck

Posterior Thorax/Lungs – observe chest for deformities, use of accessory muscles of inspiration

inspect: breathing rate/rhythm/depth/effort; inspiratory retraction of supraclavicular areas/SCM/interspaces

palpate: tender areas, respiratory expansion, tactile fremitus

percuss: five rows down, two external; identify diaphragmatic excursion

auscultate: evaluate breath sounds, note any adventitious sounds; egophony or whispered pectoriloqui

Costovertebral Angle Tenderness

Musculoskeletal (upper) – palpate: axillary and epitrochlear lymph nodes

TMJ: palpate

Shoulder:

test: out, up, behind head, behind back

palpate: acromioclavicular (crossover test), subacromial/subdeltoid bursa, rotator cuff, bicipital groove

Elbow:

test: flex/extend, supinate/pronate

palpate: olecranon process, medial/lateral epicondyles, extensor surface of ulna, grooves over joint

Wrists/Hands:

test: flex/extend/ulnar/medial deviation, finger movements

inspect: contours of wrists, hands, fingers, palms

palpate: wrist joints, distal radius/ulna, anatomic snuffbox, MCP/PIP/DIP joints

Breast

inspect: size, symmetry, contour, skin; nipples (size/shape/direction/rashes/ulcerations/discharge)

test: raise arms above head, press hands against hips

Axillae

inspect: rashes, infection, pigmentation

palpate: central axillary nodes; also pectoral, lateral, subscapular nodes

Lying Inclined (At 30° )

Cardiovascular

palpate: radial pulse (rate, rhythm); carotid pulse (amplitude/variations/contour)

auscultate: carotid

inspect: jugular veins (also measure JVP); anterior chest for pulsations

palpate: apical impulse (loc/diameter/amplitude/duration; left lateral decubitus if necessary); RV impulse (left parasternal/epigastric); left/right 2^nd interspaces

auscultate: parasternal: right 2^nd IC, left 2^nd to 5^th IC, MCL: 5^th IC (S₁/S₂ split/clicks/S₃/S₄/murmurs (timing/shape/location/radiation/intensity/pitch/quality))

left lateral decubitus for left-sided S₃/S₄, mitral stenosis murmur
leaning forward for murmur of aortic regurgitation

Lying Supine

Anterior Thorax – inspect/palpate/percuss (4 rows down (last more medial), 2 external)/auscultate as with posterior thorax

Breast – palpate: consistency, tenderness, nodules (loc/size/shape/consistency/tenderness/mobility), nipple

Abdomen

inspect: skin, umbilicus, contours (shape/symmetry/organomegaly/masses), peristaltic waves/pulsations

auscultate: bowel sounds, aortic or renal bruits, friction rubs (test all 4 quadrants)

percuss: tympany, dullness, liver (measure), spleen

palpate: lightly for guarding, rebound, tenderness; deeply for masses, tenderness; liver, spleen (supine and right lateral decubitus), kidney, aorta

Musculoskeletal (lower) – palpate: inguinal lymph nodes

Hips

palpate: along inguinal ligament, ileopectineal bursa, trochanteric bursa, ischiogluteal bursa, sciatic n.

test: flexion/extention, abduction/adduction

Knees

inspect: alignment/contour

palpate: patella/supra-/infrapatellar spaces, medial tibial condyle, popliteal surface

palpate patellar tendon then straighten leg, press patella against femur, push patella distally/tighten knee against table (chondromalacia)
flex knees: palpate medial/lateral menisci, MCL/LCL, effusions (bulge sign/balloon sign/ballot)
assess ligaments: MCL (push valgus), LCL (push varus), ACL (drawer/Lachmann), PCL (antidrawer)

Ankles

palpate: ankle joints/ligaments, achilles, compress MTP/palpate MTP

test: dorsiflex/plantarflex, invert/evert heel/forefoot, flex toes at MTP

Pulses – femoral, popliteal, dorsalis pedis, posterior tibial

Lying or Sitting

Neuro

Motor – body position, involuntary mvts

muscle bulk, tone, strength: elbow flexion/extension, wrist extension, grip, finger abduction, thumb opposition, trunk flexion/extension/lateral bending, hip flexion/extension/abduction/adduction, knee flexion/extension, ankle dorsiflexion/plantar flexion
coordination – rapid alternating movements, point-to-point movements

Sensory – light touch/pain/temp: compare symmetrical on two sides of body, proximal/distal

vibration/proprioception: distal then more proximal
stereognosis/number identification/two-point discrimination/point localization/extinction

Reflexes (use hammer) – biceps (point on thumb), triceps (point), brachioradialis (flat), upper/lower abdominals (end then flat), knee (point), ankle (flat), plantar (end)

Standing

Legs, Feet – look for varicose veins

Spine:

test: ROM in neck, flexion/extention/rotation/lateral bending

inspect, palpate: spinous process of each vertebra, sacroiliac joint, paravertebral muscles

Gait – walk/turn/come back, heel/toe, toes/heels, hop/one-leg shallow knee bends (or rise from chair/climb on stool)

Pronator Drift – pronator drift, tap down arms

Romberg

Male Rectal

inspect: sacrococcygeal and perianal areas, sphincter tone

palpate: walls of rectum, prostate gland (size/landmarks/nodules), above prostate

Male Genitalia and Hernia

inspect: development, prepuce, glans, urethral meatus; contours/skin of scrotum

palpate: shaft, testes (lumps/tenderness), epididymis, spermatic cord/adjacent areas; check for hernias

Female Pelvic/Rectal – inspect: pubic hair, external genitalia (labia/clitoris/urethral oriface/introitus)

palpate: Bartholins glans, urethra for discharge

speculum: cervix (position, color, epithelial surface, discharge/bleeding, ulcers/nodules/masses), cytology

palpate: cervix, fornices, uterus/adnexa (bimanual exam), strength of pelvic muscles, rectovaginal examination