Clinical Examination Skills: Physical Assessment Techniques

Physical Examination Foundation: Techniques and Accuracy

Proficiency in physical examination techniques enables accurate diagnosis and early detection of abnormalities. Systematic assessment of each body system ensures comprehensive evaluation. Understanding normal vs abnormal findings guides clinical decision-making.

Examination Facts:

• Physical examination sensitivity varies by finding (70-95% for major abnormalities)
• Abnormal examination findings have higher positive predictive value than normal
• Operator skill significantly affects accuracy (experience improves sensitivity)
• Comprehensive examination takes 15-30 minutes for complete patient
• Focused examination on specific system requires 5-10 minutes

Examination Techniques: Methods of Assessment

Inspection: Visual Assessment

• Definition: Careful observation without touching
• Key observations: Color, symmetry, deformity, movement, swelling
• Lighting: Bright, natural light optimal for accuracy
• Positioning: Patient positioned to visualize anatomical area
• Clothing: Appropriate exposure while maintaining dignity

Palpation: Tactile Assessment

Light Palpation

• Use fingertips with gentle pressure (1 cm depth)
• Assess surface characteristics, temperature, tenderness
• Always use light palpation before deep palpation
• Observe patient's face for signs of pain or discomfort

Deep Palpation

• Use flathand technique with moderate pressure
• Assess deeper structures (organs, masses)
• Use bimanual technique (both hands) when helpful
• Always examine tender areas last

Percussion: Sound Assessment

• Technique: Strike middle finger of one hand with finger of other
• Sounds: Resonance (normal lung), dullness (solid tissue), hyperresonance (air)
• Application: Lung assessment, liver span, ascites detection
• Practice: Requires extensive practice for accuracy

Auscultation: Listening Assessment

• Stethoscope placement: Diaphragm for high-pitched sounds, bell for low-pitched
• Technique: Listen in quiet environment, compare bilateral areas
• Heart sounds: Listen systematically at aortic, pulmonic, tricuspid, mitral areas
• Lung sounds: Listen at apices and bases, compare side-to-side

Cardiovascular Examination

Inspection and Palpation

• Observe for visible pulsations (heaves, thrills)
• Palpate apical impulse (5th intercostal space, midclavicular line)
• Note location, size (normally <2 cm), force
• Palpate for thrills (palpable murmur) over heart
• Assess carotid upstroke (brisk vs delayed)

Auscultation of Heart Sounds

• S1 (Lub): Closure of mitral and tricuspid valves
• S2 (Dub): Closure of aortic and pulmonic valves
• S3 gallop: Rapid ventricular filling (young or pathologic)
• S4 gallop: Atrial contraction against stiff ventricle
• Murmurs: Systolic, diastolic, continuous (describe timing, quality, location)

Peripheral Vascular Assessment

• Palpate carotid pulses (never simultaneously)
• Assess carotid bruits with stethoscope
• Check peripheral pulses (radial, femoral, popliteal, dorsalis pedis)
• Assess pulse quality and symmetry
• Check capillary refill (<2 seconds normal)

Respiratory Examination

Inspection

• Rate and pattern of breathing
• Accessory muscle use (indicates labored breathing)
• Chest wall symmetry and configuration
• Cyanosis (blue lips/nailbeds indicate hypoxia)
• Pursed-lip breathing or nasal flaring

Palpation

• Tactile fremitus (vibration transmission to hands)
• Chest wall tenderness
• Expansion symmetry (normal expansion ~5 cm)
• Position patient upright for accurate assessment

Percussion and Auscultation

• Percuss anterior and posterior chest
• Normal resonance in lungs, dullness at bases (heart)
• Listen at 6 anterior positions, 6 posterior positions
• Breath sounds: Vesicular (normal), bronchial (abnormal in lungs)
• Adventitious sounds: Crackles (fine/coarse), wheezes, stridor

Abdominal Examination

Inspection and Auscultation (Before Palpation)

• Observe abdomen for distention, scars, visible pulsations
• Auscultate bowel sounds (all quadrants) before palpation
• Absent bowel sounds suggest ileus
• High-pitched/tinkling suggest obstruction

Palpation

• Light palpation systematically through all quadrants
• Assess for tenderness, guarding, rebound
• Palpate liver edge (normally <2 cm below costal margin)
• Assess spleen (palpate on inspiration from patient's left side)
• Check for masses, organomegaly

Special Maneuvers

• McBurney's point: Tenderness suggests appendicitis
• Murphy's sign: Pain with inspiration over gallbladder
• Rebound tenderness: Pain on withdrawal suggests peritonitis
• Shifting dullness: Suggests ascites

Neurological Examination

Mental Status

• Alertness: Is patient awake and responding?
• Orientation: Person, place, time
• Cognition: Memory, attention, language
• Affect: Appropriate to situation

Cranial Nerves (I-XII)

• CN I (Olfactory): Smell
• CN II (Optic): Vision, visual fields, optic disc
• CN III, IV, VI (Oculomotor, Trochlear, Abducens): Eye movements
• CN V (Trigeminal): Facial sensation
• CN VII (Facial): Facial movement, taste
• CN VIII (Vestibulocochlear): Hearing
• CN IX, X (Glossopharyngeal, Vagus): Palate, gag reflex, voice
• CN XI (Accessory): Shoulder shrug, head turn
• CN XII (Hypoglossal): Tongue movement

Motor Examination

• Strength: Grade 0-5 (0=no movement, 5=normal strength)
• Tone: Normal, increased (spasticity), decreased (flaccidity)
• Coordination: Finger-to-nose test, rapid alternating movements
• Gait: Observe for ataxia, weakness, abnormal patterns

Sensory Examination

• Light touch: Use cotton wisp
• Pain: Use pin or safety pin (not broken)
• Proprioception: Finger position sense
• Vibration: Tuning fork at bony prominences
• Compare proximal and distal, bilateral areas

Key Takeaways: Examination Mastery

• Master four examination techniques (inspection, palpation, percussion, auscultation)
• Perform systematic examination system-by-system
• Compare bilateral findings and note asymmetry
• Always listen before palpating (abdominal exam)
• Understand normal vs abnormal findings for each system
• Practice frequently to develop proficiency
• Ensure patient comfort and dignity during examination
• Document findings accurately and objectively