1	Physical Assessment Head and Neck . Skin a. Inspect the skin for presence of abnormalities (lesions, rashes, scars, dryness, bruises ). Note the color of the skin. Observe for cyanosis or flushing. b. Feel for temperature (warm, cold, moist). Note for skin turgor- ability to return after being pinched up. Presence of edema (pitting/non-pitting) . Eye Observe the patient for ptosis, exopthalmos, lesions, deformities or asymmetry. Inspect the eyes and observe for pupillary response. Touch the cornea with a soft small wad of cotton; the patient should blink.
2	Eye exam continue….. Retract the eyelid to observe the color and condition of the conjunctiva. (the conjunctiva should be pink without lesion or drainage). Note any discoloration, redness, discharge, lesions. Extraocular Movement: Stand or sit 3 to 6 feet in front of the patient. Ask to follow your finger with their eyes without moving their head. Check for gaze using a cross or “H” pattern. Check convergence by moving your finger toward the bridge of the patient’s nose.
3	Pupillary reactions…… Dim the room lights as necessary. Ask the patient to look into the distance. Shine a bright light obliquely into each pupil. Look for both the direct (same eye) and consensual (other eye) reactions.It should constrict rapidly. Record pupil size in mm and any asymmetry or irregularity. Hold your finger about 10cm from the patient’s nose. Ask them to alternate looking into the distance and at your finger. Observe the pupillary response in each eye.It should constrict as they attempt to accommodate.
4	Ear………………………… Inspect the auricles and move them around gently. Ask the patient if this painful. Note for redness, drainage or deformity. If the patient uses a hearing aid, check to see that they are working, are free from wax buildup, and are properly placed in the ears. Ask the patient if there have been any recent changes in hearing ability. Test hearing by whispering in each ears.
5	Nose…………………… Tilt the patient’s head back slightly. Inspect the visible nasal structures and note any swelling, redness, drainage or deformity. Ask the patient to blow in each nostril to check for patency. Test for sense of smell.
6	Mouth…………………….. Ask the patient to open their mouth. Using a wooden tongue blade, inspect the inside of the patients mouth including the buccal folds and under the tongue. Note any ulcers, white patches (leucoplakia) or other lesions. Inspect the posterior oropharynx by depressing the tongue and asking the patient to say “Ah.” Note any tonsilar enlargement, redness or discharge. Inspect the teeth for looseness and the presence of caries. Ask to clench the teeth and smile to check for symmetrry.
7	Neck……………… Inspect the neck for asymmetry, scars, or other lesions. Palpate the neck to detect areas of tenderness, deformity or masses. A visible enlarged thyroid gland is called a goiter. Move to a position behind the patient. Identify the cricoid cartilage with fingers of both hands. Move downward two or three tracheal rings while palpating for the isthmus. Note the size, symmetry and position of the lobes, as well as the presence of any nodules. The normal gland is often not palpable.
8	Neck continue……. Palpate with your index and middle fingers for the various lymph nodes. Preauricular- in front of the ear. Postauricular – behind the ear. Occipital – At the base of the skull. Tonsillar – At the angle of the jaw. Submandibular – Under the jaw on the side. Note the size and location of any palpable nodes and whether they are soft or hard, non-tender or tender and mobile or fixed.
9	Upper Extremities and Chest Thoracic configuration Observe for retractions and use of accessory muscles (sternomastoids, abdominals). Observe the chest for asymmetry, deformity or increased AP diameter. Assess expansion and symmetry of the chest by placing your hands on the patient’s back, thumbs together at the midline and ask them to breath deeply. Note for skin color, temperature, turgor, presence of abnormalities.
10	Chest exam continue… Note any abnormal dimpling, color or discharge of the nipples. Ask the female patient to lie in the supine position, examine each breast for lumps and masses. Ask the patient to breathe slowly in and out through an open mouth. Auscultate the anterior and posterior chest comparing right and left side. Note the location and quality of the sounds you hear.
11	Chest exam continue….. Position the patient supine. Always examine from the patient’s right side. Palpate for the point of maximal impulse (PMI or apical pulse). It is normally located in the 4^th or 5^th intercostal space just medial to the midclavicular line and less than the size of a quarter. Note the location, size and quality of the impulse.
12