PHYSICAL EXAMINATION

1. General Survey
Pemeriksaan
Apparent state of health :
Status keseluruhan kondisi secara umum yang
diliat dr observasi
Level of consciousness :
Sikap terhadap orang di sekitar dan barangbarang di lingkungan
Sign of distress (Tanda Masalah)
Cardiac/Respiratory

Pain
Anxiety or depression

Height and Build

Weight
Skin color and obvious lesion
Dress, Grooming, and Personal Hygiene

Facial Expression

Odors of the body and breath

Posture, Gait and Motor Activity

2. Vital Sign

Blood Pressure

Contoh

Sakit akut
Sakit kronis
Frail
Freeble

Clutching chest, pucat, diaphoresis,

wheezing, cough
Wincing, sweating, melindungi area yg
sakit
Muka cemas, fidgety movement, cold
moist palms, flat affect, poor eye
contact
Short/ Tall
Slender and lanky/ Muscular / Stocky
Symmetric/Assymetric
Emaciated/Slender/Plump/Obese
Fat distribution
Pallor, cyanosis, jaundice, rashes, bruises
appropriate to the temperature and
weather
lean, properly buttoned, and zipped
compare with clothing worn by people
of comparable age and social group
shoes : cut, tied laces
unusual jewelry : body piercing
note the patient hair, fingernails,
cosmetics
at rest, during conversation about
specific topics, during the physical
examination, and in interaction with
others.
eye contact : natural/Sustained and
unblinking/ Averted quickly/Absent

Preffered posture
Restless/quiet
Change position : fast/slow
Involuntary motor activity
How they walks

3.

Heart Rate and Rhytm

count the rate of the heart and determine its rhythm, assess the amplitude and contour
of the pulse wave, and sometimes detect obstructions to blood flow.
Normal Values : 60-100 bpm
Respiratory Rate and Rhytm
Observe the rate, rhythm, depth, and effort of breathing
Normal Values : 14 20 breaths/min
Body Temperature
i. Average oral temperature, usually quoted at 37C (98.6F), fluctuates
considerably
ii. Rectal temperatures than oral temperatures by an average of 0.4 to 0.5C (0.7
to 0.9F)
iii. Axillary temperatures are than oral temperatures by approximately 1 degree

Skin

Inspeksi dan palpasi kulit

Color

Moisture
Temperature
Texture
Mobility and Turgor
Lesions

increased pigmentation (brownness), loss of

pigmentation, redness, pallor, cyanosis, and
yellowing of the skin
dryness, sweating, and oiliness
roughness and smoothness

Anatomic location
Arrangement
Types of skin lesion
Color

Inspeksi dan palpasi kuku

i. Color, shape, any lesion
Inspeksi dan palpasi Rambut
i. Quantity, distribution, texture

4. Head and Neck

Head
Hair
Scalp

Eyes
Ears
Nose
Throat

quantity, distribution, texture, and pattern of

if any