• The patient is conscious and oriented to time, place and person.
• In presence of female attendant (if female patient).
General Physical Examination
• Pulse: _______/min
• Blood Pressure:_____ mmHg
• Respiratory Rate: _______/min
• Temperature: ___ °F
• SpO₂:______%
• BMI:_____kg/m²
• Built and nourishment:_______
General examination findings:
Pallor: Present / Absent
Icterus: Present / Absent
Cyanosis: Present / Absent
Clubbing: Present / Absent
Lymphadenopathy: Present / Absent
Pedal edema: Present / Absent
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Inspection
Upper Respiratory Tract
Nose: Normal / Abnormal
Mouth and oral cavity: Normal / Abnormal
Upper respiratory tract: Normal / Abnormal
Trachea and Neck
Trachea: Central / Shifted to Right / Shifted to Left
Tracheal tug (Trail’s sign): Present / Absent
Neck veins: Normal / Engorged
Shape of Chest
Shape of chest: Elliptical / Barrel-shaped / Flat / Kyphoscoliotic
A.P. diameter : Transverse diameter
Spine: Central / Scoliosis / Kyphosis / Kyphoscoliosis
Chest Wall
Scars: Present / Absent
Sinuses: Present / Absent
Dilated veins: Present / Absent
Bony deformities: Present / Absent
- Pectus excavatum
- Pectus carinatum
- Harrison’s sulcus
Respiratory Movements
Respiratory movements: Symmetrical / Asymmetrical
Movement of chest: Equal bilaterally / Reduced on __ side
Intercostal indrawing: Present / Absent
Use of accessory muscles: Present / Absent
Infra-clavicular hollowness: Present / Absent
Drooping of shoulders: Present / Absent
Apex Beat
Visible: Yes / No
Site: ____________________
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Local rise of temperature: Present / Absent
Tenderness: Present / Absent
Trachea
Central / Shifted to Right / Shifted to Left
Chest Movements
Equal bilaterally / Reduced over ______________
Chest expansion: ____ cm
Chest Dimensions
A.P. diameter : Transverse diameter = ____ : ____
Equal and symmetrical / Increased over ____ / Decreased over ______ / Absent over _____
Felt / Not felt
Site: ____ intercostal space, ____cm medial/lateral to the mid-clavicular line
Character: Normal / Heaving / Hyperdynamic
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Percussion
Percussion Note
Resonant throughout / Abnormal over ______________
Abnormal note:
Dull
Stony dull
Hyper-resonant
Tympanitic
Dullness moves down by __ intercostal spaces
Normal / Restricted / Absent
Liver Dullness
Present at __ intercostal space in right mid-clavicular line
Obliterated / Not obliterated
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Auscultation
Air Entry
Equal bilaterally / Reduced over ______________
Breath Sounds
Vesicular
Bronchial
Bronchovesicular
Diminished
Absent
Intensity of Breath Sounds
Normal
Increased
Decreased
Added Sounds
• Crepitations: Present / Absent
Site: ______________
Fine / Coarse
Inspiratory / Expiratory
• Rhonchi: Present / Absent
• Pleural rub: Present / Absent
• Stridor: Present / Absent
Vocal Resonance
Equal and symmetrical
Increased over ______________region
Decreased over ___________region
Bronchophony: Present / Absent
Whispering pectoriloquy: Present / Absent
Egophony: Present / Absent
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Examination of Other Systems
Cardiovascular System
Abdomen
Soft, non tender, Bowel sounds heard
The patient is conscious and oriented to time, place and person. He/She is examined in a well-lit room, adequately exposed, in sitting position, after taking verbal consent, in presence of female attendant.
On General physical examination, His/her pulse rate is 68 beats/min, regularly regular, normal volume and character, all peripheral pulses are palpable, no radio-radial or radio-femoral delay, no vessel wall thickening. His/her Blood pressure is 128/76 mm of Hg, from right arm in sitting position, by Auscultatory method. His/Her Respiratory rate is 18 times/ min, Thoraco-abdominal/ abdomino-thoracic, without use of any accessory muscles. His/her axillary temperature is 98.6 degree F.
No Pallor, Icterus, Cyanosis, Clubbing, Edema or Lymphadenopathy.
On inspection, his/her upper respiratory tract appears to be normal. The trachea appears to be central. Train sign absent. The chest appears elliptical in shape with transverse diameter > A.P. diameter, and is bilaterally symmetrical. The spine appears central. No scars, sinuses, dilated veins or bony deformities (like pectus excavatum, pectus carinatum).
The respiratory movements appear to be symmetrical and moving equally bilaterally. No indrawing of intercostal spaces were seen. There is no usage of accessory muscles of respiration.
There is no drooping of shoulders, no supra- or infra-clavicular hollowness.
Apex beat is not visible / visible few cm below the level of nipple and medial to mid-clavicular line.
No local rise in temperature or tenderness.
On palpation, trachea is found to be central. Chest movements were decreased over the right lower anterior chest. Chest Expansion is ____ cm. (Normal: 5–8 cm, COPD/ILD < 1.5 cm)
His A.P. Diameter : Transverse diameter is __ : __ which is normal. (If 1 : 1 → Barrel shaped chest)
Vocal fremitus is felt equally & symmetrically in all the areas of the lungs.
Apex beat felt at the 5th left I/C space, 1 cm medial to mid-clavicular line.
On percussion, a dull note is noted over the right lower lobe / Resonant note is noted over all the regions. Liver dullness is noted in 5th I.C. space in right mid-clavicular line, normal in character.
Tidal percussion: On tidal percussion, the dullness moves down by 1–2 I.C. spaces. (Differentiates subdiaphragmatic from pulmonary pathology)
On auscultation, air entry is present in all areas. Vesicular breath sound is heard in all areas. Intensity of breath sound is N. Crepitations are heard in the right infra-mammary area and right infra-axillary area. Vocal resonance is heard equally and symmetrically in all the areas of the lungs.
