Physical Examination Techniques

Inspection: look at the patient systematically (skin color, rashes, symmetry, posture, movement). Palpation: use your hands to feel for temperature, tenderness, masses, firmness (e.g., palpating the abdomen four quadrants, feeling for hepatomegaly or a femoral pulse). Percussion: tap the chest or abdomen with your finger and listen to the resonance to map air (resonant), fluid (dull), or solid (dull) — used to detect pleural effusion, consolidation, or ascites. Auscultation: listen with a stethoscope to heart sounds (S1, S2, murmurs), breath sounds (crackles, wheeze, absence), bowel sounds (present or absent in paralytic ileus), or carotid bruits. Use them in sequence: inspect first, then palpate, then percuss, then auscultate (except abdomen: inspect, auscultate, percuss, palpate to avoid triggering bowel sounds).

Normal heart sounds: S1 (lub) is caused by closure of mitral and tricuspid valves at the start of systole, loudest at the apex. S2 (dub) is caused by closure of aortic and pulmonary valves at the start of diastole, loudest at the right upper sternal border. A murmur is an abnormal swooshing or blowing sound caused by turbulent blood flow through a valve or across a defect. Systolic murmurs (between S1 and S2) may be innocent (flow murmur in anemia or pregnancy) or pathological (mitral regurgitation, aortic stenosis). Diastolic murmurs are almost always pathological (aortic regurgitation, mitral stenosis). Grade murmurs I–VI by loudness: Grade I is barely audible, Grade VI is audible without a stethoscope. A new murmur warrants echocardiography and cardiology referral.

Normal breath sounds: vesicular (soft, quiet, heard over the lung periphery) and bronchial (louder, harsher, heard over the trachea). Crackles (rales) are discontinuous popping sounds on inspiration caused by alveoli opening (fine, high-pitched at lung bases in heart failure or pneumonia; coarse, lower-pitched in pulmonary edema). Wheezes are continuous musical high-pitched sounds on expiration, signaling bronchospasm or asthma. Stridor is a high-pitched breathing sound on inspiration, indicating upper airway obstruction (croup, epiglottitis). Rhonchi are low-pitched coarse sounds from thick secretions. Diminished breath sounds mean reduced air movement (emphysema, pneumonia, pleural effusion). Absent breath sounds mean no air movement (pneumothorax, large effusion). Document location (upper lobes, bases) and whether it clears with coughing.

Start with inspection (distension, scars, skin changes, visible pulsations). Auscultate all four quadrants for bowel sounds (normal = 5–30 per minute, present, clicking). Percuss for tympany (air) and dullness (fluid or mass). Palpate each quadrant gently, watching for guarding (muscle tensioning from pain or peritonitis) or rebound tenderness (pain on release after pressing). Palpate for organ borders (liver edge 1–2 cm below right costal margin, spleen normally impalpable), masses, or fluid wave. Mcburney's point tenderness (right lower quadrant) suggests appendicitis. Right upper quadrant tenderness with inspiratory arrest (Murphy's sign) suggests cholecystitis. Severe distension, rigidity, and rebound indicate acute peritonitis — call the surgeon. Absent bowel sounds + abdominal distension = paralytic ileus or obstruction.

Test mental status (alert, oriented to person/place/time, memory, concentration). Cranial nerves: I (smell), II (vision and fields), III/IV/VI (eye movement), V (facial sensation and jaw strength), VII (facial symmetry and movement), VIII (hearing), IX/X (voice, palate elevation, gag), XI (shoulder shrug, neck rotation), XII (tongue midline and strength). Motor: assess strength 0–5 in major muscle groups (hip flexors, knee extension, ankle dorsiflexion, grip). Sensory: test light touch, temperature, and vibration in the arms and legs. Reflexes: test biceps, triceps, patellar, and Achilles (normal = 2+ brisk and equal). Gait: observe walking for stability and coordination. Cerebellar: test Romberg test (stand with eyes closed, feet together for 20 seconds without falling) and finger-to-nose (touch your nose then the examiner's finger, back and forth). Abnormal findings (weakness on one side, absent reflexes, Babinski reflex upgoing) suggest stroke, neuropathy, or central nervous system disease.

Inspect all skin systematically (head, neck, chest, abdomen, extremities, back) under good lighting. Look for color (pale, flushed, cyanotic, jaundice), integrity (rashes, wounds, ulcers), and lesions. Palpate for temperature (warm vs. cold), moisture, and turgor (pinch skin on forearm; normal skin returns to baseline within two seconds; slow turgor = dehydration). Describe lesions by type (macule <5mm flat, papule <5mm raised, plaque >5mm raised, vesicle with fluid, pustule with pus, scale, crust), distribution (localized vs. widespread, symmetric vs. asymmetric), and color. Document size in centimeters and location by body region. A pressure injury is staged I–IV by depth; a wound by size, depth, exudate, and surrounding skin. A mole with irregular borders, dark color, asymmetry, or rapid growth needs dermatology referral (melanoma screening ABCDE rule).

A focused exam targets the systems relevant to the chief complaint and history. A patient with an ankle sprain gets a detailed ankle and knee exam plus bilateral comparison, not a full head-to-toe. An acute chest pain gets cardiac and respiratory exams plus vital signs, not a full neuro exam. A follow-up diabetic foot check focuses on sensation, pulses, and skin integrity, not every nerve in the body. Focused exams are faster, more efficient, and still thorough within scope. A full exam (head-to-toe, all systems) is appropriate at a new patient visit or hospital admission, or when the history is vague and you are fishing for abnormalities. Always do a focused exam if time-limited, but document what systems you assessed so it is clear you were thorough within scope.