B. R NATH PAI COLLEGE OF (M.

SC)
NURSING, KUDAL

ASSIGNMENT
ON
PHYSICAL
EXAMINATION
SUBJECT: MEDICAL SURGICAL NURSING

SUBMITTED BY:
Name: MS ASHWINI MACWAN
College: B. R PATH NAI COLLOGE OF MSC NURSING

SUBMITTED TO:
Teacher’s Name: MS TANMAYA SAWANT
Department: MEDICAL SURGICAL NURSING
 RESPIRATORY SYSTEM

Upper Respiratory Tract

INSPECTION: No nasal deformity, No DNS, Normal nasal flora, No Nasal turbinate,

No Nasal Polyp.
PALPATION: No sinus & Nasal Tenderness.

Lower Respiratory Tract:

INSPECTION:

No chest deformity,
Trachea central in position,
Chest movements are bilaterally symmetrical,
No intercostal indrawing.
PALPATION:
No tracheal deviation- Trachea central in position.
No local rise of temperature.
No local tenderness.
No intercostal, rib tenderness.
Anterior, Posterior, Apical chest movements are normal.
Chest Measurement- Normal Antero Posterior (AP) Transverse (T) diameter.
Normal vocal fremitus all over lung field.
PERCUSSION:
Normal resonance sound heard all over the lung field.
AUSCULTATION:
Normal Vesicular Bronchial breath sound heard over lung field.
Vocal resonance are normal all over lung field.
No added sounds.
 CARDIOVASCULAR SYSTEM

HANDS/WRISTS/FINGERS
No Clubbing.
No Cyanosis.
No Splinter hemorrhages, Janeway lesions, Osler’s nodes
No signs of Raynaud’s phenomenon
Radial pulses are palpable- 72/min normal rate, rhythm, character and volume,
no radio-radial delay & No radial- femoral delay.

LEGS
No Pedal edema.
Pulses- Dorsalis pedis, Posterior tibialis are palpable

HEAD/NECK

No Corneal Arcus
No Xanthelasma
Carotid Pulses are palpable and normal.
JVP is normal 3 cm.

INSPECTION:
No Precordial bulge,
No sternal Deformity,
No spinal
abnormalities, No
visible pulsations, No
scar, discoloration.
PALPATION
: Apex beat are palpable, normal, palpated at the 5th intercostal space, just
medial to the midclavicular line.
No parasternal heaves or thrills.
PERCUSSION:
Cardiac borders are normal with in limit.
AUSCULTATION:
Normal S1, S2 heard.

Mitral Area–S1, heard on 5th intercostal space, left midclavicular line.

Tricuspid Area–S1, heard on 4th intercostal space, left sternal edge.
Pulmonary Area–S2, heard on 2nd intercostal space, left upper sternal edge
Aortic Area -S2, Heard on 2nd intercostal space, right upper sternal edge

No murmur heard
 CENTRAL NERVOUS SYSTEM:

MENTAL STATUS:
Conscious, Appearance & behavior – Normal, Memory intact, Emotions- no apparent
distress, Orientation to time, place, person; No- Illutionhallucination, delusion
Language & speech: Speech is clear and fluent with good repetition.

CRANIAL NERVES:
I. Olfaction intact by identifying the smell of coffee, Powder.
II. Visual acuity is good bilaterally, Visual fields are full to confrontation in all
quadrants. Pupils are equally round and reactive to light and accommodation.
III, IV, VI. Extraocular movements are intact, no ptosis, normal pursuits, normal
saccades, down and upward gaze normal, direct & indirect pupillary reflex are
normal.
V. Sensory over the face (V) corneal reflux is intact and equal bilaterally in all three CN
V divisions for sharp, dull, and light touch stimuli. Motor is intact with midline
location of the jaw and equal contraction during mastication.
VII. Face is symmetric with normal eye closure and smile, Facial muscle strength is
normal and equal bilaterally.
VIII. Hearing is grossly intact bilaterally. Weber does not lateralize and AC > BC (normal
Rinne) in both ears
IX, X. The palate and uvula elevate symmetrically, with an intact gag reflex bilaterally and a
normal voice.
XI. Shoulder shrug and head turning via trapezius and sternocleidomastoid is strong and
equal bilaterally
XII. Tongue protrudes midline and moves symmetrically with no fasciculation, normal
power.
MOTOR SYSTEM:
Muscle bulk and tone are normal in all limbs. Power – grade 5 both UL & LL.
REFLEXES:
Biceps, Brachioradialis, Triceps, Patellar, and knee (Achilles) reflexes are intact
bilaterally; no clonus. Plantar (Babinski) is down going bilaterally.
No involuntary movements.
SENSORY:
Spinothalamic Tract: pain, Temperature, crude touch are intact.
Posterior column: Joint position, vibration, along with light touch are intact.
Cortical sensation: discrimination intact with: localization, 2-point
 discrimination, stereognosis, and graphesthesia. Romberg is negative with no
pronator drift.
CEREBELLAR SIGN:
Finger-to-nose, and heel-along-shin -intact.
Romberg—maintains balance with eyes closed. No pronator drifts.
Coordination is good as measured by tandem walk, Straight line walk.
GAIT-Gait steady with normal base
MENINGEAL SIGNS:
No signs of meningeal irritation.
SKULL AND SPINE- Normal in examination.
 GASTRO INTESTINAL SYSTEM:

INSPECTION:
No - Scars, abdominal distension, focal swelling, asymmetry,
dilated/prominent veins, visible peristalsis, obvious pulsation, skin
discoloration.
AUSCULTATION:
Normal bowel sounds, no abnormal abdominal sounds heard.
PERCUSSION:
On the right upper quadrant, the dullness of liver; on the left the tympanic
sound percussed
PALPATION
:
Light Palpation- No pain, Rebound Tenderness.

Deep Palpation- No Pain, Tenderness Liver, Spleen, Bladder, Renal are not
palpable.

(***in case of GIT complaints goes for organ examination in detail)

 MUSCULOSKELETAL PHYSICAL EXAMINATION

1. INSPECTION

 Posture: Abnormal (patient unable to maintain erect posture due to weakness)

 Body alignment: Asymmetrical
 Gait: Unable to walk / unsteady gait
 Muscle bulk: Reduced on affected side
 Deformities: Absent
 Swelling: Not present
 Involuntary movements: Absent
 Use of assistive devices: Required (support needed for movement)

2. PALPATION

 Muscle tone: Decreased on affected side

 Tenderness: Absent
 Warmth: Normal
 Swelling: Not palpable
 Joint stability: Reduced on affected side

3. RANGE OF MOTION (ROM)

 Active movements: Restricted on affected side

 Passive movements: Possible but limited
 Joint stiffness: Present
 Pain during movement: Mild discomfort

4. MUSCLE STRENGTH

(Using grading scale)

 Right upper limb: 5/5

 Right lower limb: 5/5
 Left upper limb: 2/5
  Left lower limb: 2/5

→ Indicates hemiparesis on left side

5. COORDINATION

 Finger-to-nose test: Impaired

 Heel-to-shin test: Impaired
 Rapid alternating movements: Poor

6. REFLEXES

 Deep tendon reflexes: Increased (hyperreflexia)

 Babinski reflex: Positive
 Superficial reflexes: Reduced

7. GAIT AND BALANCE

 Gait: Unable to walk independently

 Balance: Poor
 Risk of fall: High

8. JOINT ASSESSMENT

 No deformities
 No redness or swelling
 Limited mobility on affected side

9. FUNCTIONAL ABILITY

 Activities of daily living: Dependent

 Mobility: Restricted
 Requires assistance for movement
 INTEGUMENTARY PHYSICAL EXAMINATION

1. INSPECTION

 Skin color: Normal / slightly pale

 Cyanosis: Absent
 Jaundice: Absent
 Pallor: Mild (if present)
 Skin integrity: Intact
 Lesions: Absent
 Rashes: Not present
 Scars/Wounds: Absent (or surgical scar if present)
 Pressure sores: Not present (risk present due to immobility)
 Edema: Absent
 Moisture: Slightly dry

2. PALPATION

 Skin temperature: Warm

 Texture: Smooth
 Turgor: Reduced (slow return indicating mild dehydration)
 Tenderness: Absent
 Edema: Not palpable

3. HAIR ASSESSMENT

 Distribution: Normal
 Texture: Dry
 Hair loss: Not significant
 Scalp condition: Clean, no dandruff or lesions

4. NAIL ASSESSMENT
  Color: Pink

 Shape: Normal
 Clubbing: Absent
 Capillary refill time: < 2 seconds
 Nail bed: Healthy

5. HYGIENE STATUS

 Personal hygiene: Fair

 Cleanliness: Needs assistance
 Odor: Absent

6. RISK ASSESSMENT

 Risk of pressure ulcers: High (due to immobility)

 Skin breakdown: Possible if care not maintained
 Preventive measures required: Frequent position change, skin care
 OTORHINOLARYNGOLOGICAL (ENT) PHYSICAL EXAMINATION

1. EARS
Inspection

 External ear: Normal shape and size

 Symmetry: Bilaterally symmetrical
 Discharge: Absent
 Lesions: Not present

Palpation

 Tenderness: Absent
 Swelling: Absent

Hearing Assessment

 Hearing ability: Slightly reduced / normal

 Response to sound: Present

2. NOSE
Inspection

 External nose: Normal

 Nasal septum: Midline
 Discharge: Absent
 Bleeding: Not present

Palpation

 Tenderness: Absent
 Sinus tenderness: Absent

3. THROAT (PHARYNX & LARYNX)

Inspection

 Oral mucosa: Pink

 Tonsils: Not enlarged

 Uvula: Midline
 Inflammation: Absent

Function

 Swallowing: Difficulty present (common in neurological condition)

 Voice: Slurred speech

OPHTHALMOLOGIC PHYSICAL EXAMINATION

1. INSPECTION

 Eyebrows: Symmetrical
 Eyelids: Normal, no drooping / mild drooping on affected side
 Conjunctiva: Pink
 Sclera: White
 Discharge: Absent

2. PUPILLARY ASSESSMENT

 Pupils: Equal / may be unequal

 Size: Normal
 Reaction to light: Sluggish
 Accommodation: Impaired

3. VISION

 Visual acuity: Reduced

 Blurred vision: Present
 Diplopia (double vision): May be present

4. EXTRAOCULAR MOVEMENTS

 Eye movements: Restricted

 Coordination: Impaired

5. REFLEXES

 Corneal reflex: Present

 Blink reflex: Reduced