Physical Examination

The hands-on art of diagnosis. Learn the techniques and systematic approach to reading the body's signs.

Explore Techniques

Core Components of the Exam

A great physical exam is a blend of observation, technique, and systematic process. Click any section to learn more.

The General Survey

What you learn in the first 30 seconds. Assessing distress, appearance, body habitus, and vital signs.

The 4 Core Techniques

The "how-to" of the exam: Inspection, Palpation, Percussion, and Auscultation.

A Systematic Approach

Organizing your exam, from the classic head-to-toe method to a focused, hypothesis-driven systems exam.

Clinical Correlation

Putting it all together. How to integrate your physical findings with the patient's history to form a diagnosis.

The Hands-On Detective: A Guide to the Physical Examination

In a world of high-tech imaging, the clinician's hands, eyes, and ears remain the most vital tools. Learn to master the "doing" part of diagnosis.

If the patient's history is the *story* of the illness, the **physical examination** is the *evidence*. It is the structured, hands-on process of using your senses to gather objective, physical data—or "signs"—directly from the patient's body. While modern technology like CT and MRI scans are incredibly powerful, they are not a replacement for a skilled physical exam. The exam is fast, free, non-invasive, and can be performed anywhere, at any time. It provides immediate, real-time information that confirms or refutes the hypotheses you generated during the history and guides your decision to order those high-tech tests in the first place.

Learning the physical exam is not about memorizing a sequence of movements. It's about understanding *what* you are looking for, *why* you are doing each maneuver, and *what* the findings mean. This guide explores the foundational components of a great physical exam, from the first impression to the four cardinal techniques and a systematic approach to putting it all together.

1. The General Survey: What You See in 30 Seconds

Your physical exam begins the *moment* you walk into the room. Before you even say hello, you are gathering data. This initial "gestalt" or general survey is often the source of your most important clues.

Key Components:

Level of Distress:** Is the patient in acute distress? Are they sitting forward, gasping for breath (tripoding)? Are they clutching their chest? Are they writhing in pain (like in a kidney stone) or lying perfectly still (like in peritonitis)? This single observation sets the entire pace of the encounter.

Appearance vs. Stated Age:** Does the patient "look their age," or do they appear much older (suggesting chronic illness) or disheveled (suggesting self-neglect)?

Body Habitus:** Are they well-nourished, obese, or frail and cachectic (suggesting advanced cancer or heart failure)?

Obvious Signs:** Are there any immediate, striking features? For example, are they jaundiced (yellow skin), cyanotic (blue lips), pale (anemic), or do they have visible tremors?

Gait and Posture:** How do they walk into the room? A shuffling gait might suggest Parkinson's disease. Are they guarding one side of their body?

Vital Signs:** Though often taken by a nurse, the vitals (Blood Pressure, Heart Rate, Respiratory Rate, Temperature, Oxygen Saturation) are a critical, objective part of the exam. A fever suggests infection; tachycardia (fast heart rate) suggests distress; low oxygen suggests respiratory or cardiac compromise.

The general survey is your "System 1" (fast, intuitive) thinking in action, generating your initial set of hypotheses before you even touch the patient.

2. The 4 Core Techniques: Your Diagnostic Toolkit

The entire physical exam is built upon four cardinal techniques. Except for the abdomen (where you auscultate *before* palpating to avoid altering bowel sounds), they are almost always performed in this order.

A. Inspection (What do you see?)

Inspection is the most important and most frequently overlooked technique. It is the simple, focused act of *looking*. It requires good lighting, full exposure of the area (while maintaining dignity), and comparing one side of the body to the other. Are the pupils equal? Is the chest expansion symmetrical? Is one leg more swollen than the other? Are there any subtle rashes, scars, or pulsations? You cannot find what you do not look for.

B. Palpation (What do you feel?)

Palpation is the art of using touch to assess the body. Different parts of your hand are used for different tasks:

Fingertips:** Best for fine tactile discrimination (e.g., feeling for lymph nodes, assessing a pulse, checking skin turgor).

Dorsum (Back) of Hand:** Best for assessing temperature.

Palmar (Palm) / Ulnar Surface:** Best for feeling vibrations (e.g., a "thrill" from a heart murmur or "fremitus" from the lungs).

Palpation can be light (for skin texture and superficial tenderness) or deep (to assess underlying organs like the liver and spleen, or to check for deep masses). You are assessing for tenderness, size, shape, consistency (soft, firm, hard), mobility, and temperature.

C. Percussion (What do you hear?)

This is the most technically difficult skill to master. Percussion involves tapping your middle finger (the "plexor") on the middle finger of your other hand (the "pleximeter"), which is placed firmly on the patient's body. This creates a vibration and a sound that tells you about the density of the tissue *underneath*. The key sounds are:

Resonant:** A deep, full, and hollow sound. This is the normal sound over healthy, air-filled lungs.

Dull:** A short, flat, thud-like sound. This is heard over solid organs like the liver or spleen. **Clinical Pearl:** When this sound is heard over the lungs, it means the air has been replaced by something solid or liquid (e.g., pneumonia, tumor, or pleural effusion).

Tympanic:** A hollow, high-pitched, drum-like sound. This is heard over air-filled structures like the stomach bubble or a gas-filled bowel.

Hyperresonant:** A very loud, "booming," low-pitched sound. This indicates *too much* air, as seen in a pneumothorax (collapsed lung) or emphysema.

D. Auscultation (What do you listen for?)

Auscultation is the act of listening to internal body sounds with a stethoscope. A stethoscope has two sides for a reason:

Diaphragm (Larger side):** Use firm pressure. Best for high-pitched sounds like normal heart sounds (S1, S2), lung sounds, and bowel sounds.

Bell (Smaller side):** Use light pressure. Best for low-pitched sounds, such as abnormal heart sounds (S3, S4) and vascular bruits (the "whooshing" of turbulent blood flow in a narrowed artery).

The key to auscultation is to close your eyes, focus, and ask yourself specific questions: "Are the lung sounds clear?" "Is the heart rhythm regular?" "Do I hear any extra sounds, murmurs, or rubs?"

3. A Systematic Approach: Organizing the Exam

A disorganized exam is an incomplete exam. You will miss findings. You must develop a consistent, efficient, and logical routine. There are two main ways to organize an exam, and in practice, you will use a blend of both.

The "Head-to-Toe" Comprehensive Exam

This is what you learn in medical school. It's a systematic, all-encompassing exam that checks every body system in a logical sequence. It is performed on new patients, for an annual physical, or when the diagnosis is unclear. A typical (abbreviated) flow is:

General Survey & Vitals

Head & Neck:** Inspect head/scalp, check eyes (pupils, EOMs, fundoscopy), ears (otoscopy), nose, throat. Palpate lymph nodes, thyroid, carotid arteries.

Cardiovascular:** Auscultate heart sounds (all 4 areas with bell/diaphragm). Palpate for the apical impulse. Check JVP, look for edema.

Pulmonary:** Inspect chest wall. Palpate for fremitus. Percuss lung fields. Auscultate lung sounds in all fields (anterior, posterior, axillary).

Abdominal:** **(Change order here: I-A-P-P)**. **I**nspect for scars/distension. **A**uscultate for bowel sounds. **P**ercuss for tympany/dullness. **P**alpate (light then deep) in all four quadrants.

Extremities:** Inspect skin, nails (clubbing). Palpate pulses (radial, DP, PT). Check for edema, calf tenderness.

Neurological:** Assess mental status (A&O x 3), cranial nerves, motor strength, sensation (light touch, pinprick), reflexes, and coordination (finger-to-nose), and observe gait.

The "Hypothesis-Driven" Focused Exam

In the real world, especially in an emergency or a follow-up visit, you don't do a full head-to-toe exam on every patient. Instead, you perform a **focused exam** guided by the patient's chief complaint and your differential diagnosis from the history.

Example:** A patient complains of shortness of breath. Your history suggests heart failure or pneumonia. Your *focused* exam will include:

Vitals:** (Key!)

General:** Are they in distress? Using accessory muscles?

Neck:** Check for **JVD** (a sign of fluid overload in heart failure).

Pulmonary:** Auscultate for **crackles** (fluid in lungs, for heart failure/pneumonia) or **wheezes** (asthma). Percuss for **dullness** (pneumonia/effusion).

Cardiac:** Auscultate for an **S3 gallop** (a key sign of heart failure).

Extremities:** Check for **pitting edema** in the legs (fluid overload).

In this way, the history guides the exam, and the exam findings refine the history, in a continuous diagnostic loop.

4. Putting It All Together: From Signs to Synthesis

A physical exam finding, or "sign," is a piece of objective evidence. Your job is to integrate these signs with the patient's subjective symptoms (from the history) to form a coherent diagnosis.

Connecting History and Exam

The patient *says* (history): "I feel like my heart is racing." Your exam *finds* (sign): An irregularly irregular pulse at 130 bpm. **Diagnosis:** Atrial Fibrillation.

The patient *says*: "It hurts to breathe in." Your exam *finds*: A friction rub on auscultation. **Diagnosis:** Pleurisy or Pericarditis.

The patient *says*: "I have a cough and fever." Your exam *finds*: Dullness to percussion and crackles in the right lower lobe. **Diagnosis:** Pneumonia.

How to Practice and Improve

The physical exam is a skill of "feel" and "sound" that cannot be learned from a book alone. It requires **deliberate practice**.

Practice on Peers:** Practice on your fellow students. Learn what *normal* feels and sounds like. You can't recognize an enlarged liver if you've never felt a normal one. You can't hear a murmur if you haven't listened to hundreds of normal S1/S2s.

Be Systematic:** Never deviate from your chosen system. Every time. This builds muscle memory and ensures you don't miss things.

Be Respectful:** Always be professional. Explain what you are doing ("I'm going to listen to your lungs now, please take some deep breaths"). Maintain patient dignity, using drapes appropriately.

Seek Feedback:** After you examine a patient, present your findings to a resident or attending. Then ask them to confirm your findings or show you what you missed. This is the fastest way to improve.

Conclusion: The Enduring Craft

In a world of rapidly advancing technology, the physical examination remains the indispensable, human-centered core of medicine. It is a procedure, a skill, and an art form. It builds rapport, provides immediate data, and focuses all subsequent diagnostic testing. Mastering the techniques of inspection, palpation, percussion, and auscultation, and applying them in a systematic, hypothesis-driven way, is what transforms a student from a book-learner into a clinician. Your hands, eyes, and ears are your most advanced, reliable, and always-available diagnostic tools—learn to trust and hone them.

Physical Examination FAQs

Your common questions about the hands-on exam, answered.

What's the difference between a "sign" and a "symptom"?

This is a fundamental distinction. A Symptom is what the *patient tells you* (it's subjective). Examples: "I feel nauseous," "I have chest pain," "I feel dizzy."
A Sign is what *you find* on your physical exam (it's objective). Examples: "The patient has a tender abdomen," "I hear a heart murmur," "The patient has 2+ pitting edema."
The history is for gathering symptoms; the exam is for finding signs.

Why do I have to percuss? I can't hear any difference.

Percussion is the hardest skill to learn, and many students struggle with it. Don't worry! The differences are subtle. The key is to practice on yourself (e.g., percuss your chest, then your abdomen, then your thigh to hear resonant, tympanic, and flat sounds). It's most useful for: 1) Finding the top of the liver. 2) Detecting a large pleural effusion (which will be "stony dull"). 3) Detecting a severe pneumothorax (which will be "hyperresonant"). Keep practicing, it will eventually click!

What is the difference between the bell and diaphragm on a stethoscope?

They are designed for different frequencies.

The **Diaphragm** (the flat, wide side) is for **high-pitched** sounds. You must press it firmly against the skin. Use it for: lung sounds, bowel sounds, and normal heart sounds (S1, S2).

The **Bell** (the small, cupped side) is for **low-pitched** sounds. You must rest it *very lightly* on the skin. Use it for: abnormal heart sounds (S3, S4) and vascular sounds (bruits, hums).

Why do you examine the abdomen in a different order (Inspection, Auscultation, Percussion, Palpation)?

This is a classic exam question! You **auscultate (listen) *before* you percuss or palpate** the abdomen because vigorously pushing and tapping (palpating and percussing) can disturb the intestines and artificially alter the patient's **bowel sounds**. You want to listen to them in their natural, undisturbed state. For all other body systems, the order doesn't matter, so we use the traditional I-P-P-A sequence.

With all our modern scans, is the physical exam still relevant?

Absolutely. It is more relevant than ever. A good physical exam is fast, free, and can be done at the bedside *immediately*. It helps you narrow down your differential diagnosis *before* you order an expensive or radiation-heavy scan. For example, a good exam can tell you if a patient's shortness of breath is more likely heart failure (JVD, S3, edema) or pneumonia (fever, crackles, dullness to percussion), allowing you to order the *right* follow-up tests (like an echo vs. a chest X-ray) instead of just "scanning everything."