General Principles of

Physical Examination


Made Ratna Saraswati
Internal Medicine Department, Faculty
of Medicine Udayana University/
Sanglah Hospital
Refference:
Bates Guide to Physical Examination and History
Taking 8th edition. Lynn S Bickley, Peter G.
Szilagyi. Lippincott William & Wilkins, Philadelphia,
2003
Textbook of Physical Diagnosis, history and
examination, 2nd edition. Mark H Swartz, WB
Saunders, Philadelphia
On most new patients or patients being
admitted to the hospital, you will conduct a
comprehensive physical examination.
The key to a thorough and accurate physical
examination is developing a systemic sequence
of examination.
As you develop your own sequence of
examination, an important goal is to minimize
the number of times you ask the patient to
change position from supine to sitting, or
standing to lying supine.
Beginning the examination:
Setting the stage
Preparing for the physical examination:
1. Reflect on your approach to the patient
2. Decide on the scope of the examination
3. Choose the examination sequence
4. Adjust the lighting and the environment
5. Make the patient comfortable

Make sure that you wash your hands in the presence of
the patient before beginning the examination, this is a
subtle yet much appreciated gesture of concern for the
patients welfare.
1. Approaching the patient
When the first examining patients, feelings of insecurity
are inevitable.
Be straightforward. Let the patient know you are a
student and try to appear calm, organized, and
competent.
If you forget to do part of the examination, simply
examine those area out of sequence, but smoothly.
Avoid interpreting your findings, your views may be
conflicting or in error.
Always avoid showing distaste, alarm, or other negative
reactions.
2. Decide on the scope of the examination:
How complete should it be?
No simple answer
As a general principle: a new patient warrants a
complete examinations, regardless of chief complain
or setting. You may choose to abbreviate the
examination for patients making routine office visits
or seeking urgent care. A more limited examination
may also appropriate for patients with symptoms
restricted to a specific body system or with patients
you know well.
3. Choose the examination sequence
The sequence should maximize the patients
comfort, avoid unnecessary changes in position,
and enhance the clinicians efficiency. In general,
move from head to toe.
An important goal for you as a student is to
develop your own sequence of examination with
this principles in mind
4. Adjusting the lighting and the environment
As the examiner, you will find that awkward
positions impair the quality of your observations.
Take the time to adjust the bed to a convenient
height (but be sure to lower it when finished) and
ask patient to move toward you if this makes it
easier to examine a region of the body more
carefully.
Good lighting and a quiet environment make
important contribution to what you see and hear.
5. Make the patient comfortable
Your access to the patients body is a unique and
time-honored privilege of your role as a clinician.
Be sure to close nearby doors and draw the curtains
in the hospital or examining room before the
examination begins.
Your goal is to visualize one area of the body at a
time. This preserves the patients modesty but also
help you to focus on the area being examined.
Keep the patient informed, especially when you
anticipate embarrassment or discomfort.
Equipment for Physical Examination
Available in most
patient care areas
Required Optional
Sphygmomanometer
Tongue blade
Gloves
Lubricant gel
Vaginal speculum
Stethoscope
Oto/ophthalmoscope
Penlight
Reflex hammer
Tuning fork 128 Hz
Pin
Tape measure
Nasal Iluminator
Nasal speculum
Tuning fork 512 Hz
Textbook of Physical Diagnosis, history and examination, 2nd edition. Mark H Swartz, WB Saunders, Philadelphia
The four cardinal principles of
physical examination:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
1. Inspection
Inspection can provide an enormous amount of
information. Examiners must train themselves
to look at the body using a systematic
approach.
2. Palpation
Palpation is the use of tactile sense to
determine the characteristics of an organ
system.

3. Percussion
Percussion relates to the tactile sensation and
sound produced when a sharp blow is struck to
an area being examined.
Provide valuable information about the structure
of the underlying organ or tissue.

4. Auscultation
Auscultation involves listening to sounds
produced by internal organs. This instrument
should corroborate the signs that were
suggested the other techniques.
Auscultation should be not used alone to
examine the heart, chest, and abdomen.
This technique should be used together with
inspection, percussion, and palpation.
The Comprehensive
Physical examination
General survey
Vital sign
Skin
Head, eyes, ears, nose, throat (HEENT)
Neck
Back
Superior thorax and lungs
Breast, axillae, and epitrochlear nodes
Anterior thorax and lungs
Cardiovascular system
Abdomen
Lower Extremities
Nervous system
Additional examination
rectal examination in men
genital and rectal examination in women
1. General survey
Observe the patients general state of health, height,
build and sexual development.
Obtain the patient weight.
Note posture, motor activity, and gait; dress, grooming,
and personal hygiene; and any odors of the body or
breath.
Watch the patients facial expressions and note the
manner, affect and reactions to person an things in the
environment.
Listen to the patients manner of speaking and note the
state of awareness of level of consciousness.
2. Vital sign
The patient is sitting on the edge of the bed or
examining table, unless this position is
contraindicated. You should be standing in
front of the patient, moving to either side if
needed.
Measure height, weight.
Measure blood pressure.
Count the pulse and respiratory rate.
If indicated, measure the body temperature.
3. Skin
Observe the skin of the face and its characteristics.
Identify any lesions, noting their location,
distribution, arrangement, type, and color.
Inspect and palpate the hair and nails. Study the
patients hands.
Continue your assessment of the skin as you
examine the other body regions.

4. Head, eyes, ears, nose, throat
Head: examine the hair, scalp, skull and face.
Eyes: check visual acuity and screen the visual fields.
Note the position and alignment of the eyes. Observe
the eyelids and inspect the sclera and conjunctiva of
each eye. With oblique lighting, inspect each cornea,
iris, and lens. Compare the pupils and test their
reactions to light. Assess the extraocular movement.
With ophthalmoscope inspect the ocular fundi.
Ears: inspect the auricles, canals, and drums. Check
auditory acuity. If acuity is diminished, check
lateralization (Weber test), and compare air and bone
conduction (Rinne test).
Nose and sinuses: Examine the external nose; using a
light and a nasal speculum, inspect the nose mucosa,
septum and turbinates. Palpate for tenderness of the
frontal and maxillary sinuses.
Throat (or mouth and pharynx): inspect the lips, oral
mucosa, gums, teeth, tongue, palate, tonsils, and
pharynx.
You may wish to assess the cranial nerves during this
portion of examination.
5. Neck
Inspect and palpate the cervical lymph nodes.
Note any masses or unusual pulsation in the
neck. Feel for any deviation of the trachea.
Observe sound and effort of the patients
breathing. Inspect and palpate the thyroid
gland.
(move behind the sitting patient to feel the
thyroid gland and to examine the back,
posterior thorax , and the lung)
6. Back

Inspect and palpate the spine and muscles
of the back
7. Superior thorax and lungs
Inspect and palpate the spine and muscles of the
upper back.
Inspect, palpate and percuss the chest. Identify
the level of diaphragmatic dullness on each side.
Listen to the breath sound; identify any
adventitious (or added) sounds, and if indicated,
listen to the transmitted voice sounds.
8. Breast, axillae, and epitrochlear nodes
The patient is still sitting, move to the front again
In woman, inspect the breast with her arms relaxed,
then elevated, and then with her hands pressed on her
hip.
In either sex, inspect the axillae and feel for the axillary
nodes. Feel the epitrochlear nodes
A note on the musculoskeletal system: by this time you
have made some preliminary observations of the
musculoskeletal system. Use these to decide whether a
full musculoskeletal examination is warranted.
9. Anterior thorax and lungs
The patient position is supine, ask the patient to lie
down, You should stand at the right side of the
patients bed.
Inspect, palpate, and percuss the chest.
Listen to the breath sound, any adventitious
sounds, and, if indicated transmitted voice sounds.
10. Cardiovascular system
Elevated the head of the bed to about 30
o
.
Ask the patient to roll partly onto the left side
while you listen at the apex, then have the patient
roll back to the supine position while you listen to
the rest of the heart. The patient should sit, lean
forward, and exhale while you listen for the
murmur of aortic regurgitation.
Observe the jugular venous pulsations, and
measure the jugular venous pressure in relation to
the sternal angle.
Inspect and palpated the carotid pulsation.
Listen for carotid bruits.
Inspect and palpate the precordium. Note the
location, diameter, amplitude, and duration of the
apical impulse. Listen at the apex and the lower
sternal border with the bell of the sthetoscope.
Listen at the auscultatory area with the diaphragm.
Listen to the first and second sound. Listen for any
abnormal heart sounds or murmurs.

11. Abdomen
Lower the head of the bed to the flat position, the
patient should be supine
Inspect, auscultate, and percuss the abdomen.
Palpate lightly, the deeply.
Assess the liver and spleen by percussion and then
palpation.
Try to feel the kidneys, and palpate the aorta and
its pulsations. If you suspect kidney infection,
percuss posteriorly over the costovertebral angles.
12. Lower Extremities

Examine the legs, assessing three systems while
the patient is still supine. Each of these three
systems can be further assessed when the patient
stands.
13. Nervous system
The complete examination of the nervous system
can also be done at the end of the examination. It
consists of five segments:
mental status
cranial nerves (including funduscopic examination)
motor system
sensory system
reflexes.
14. Additional examination
Rectal examination in men
The patient is lying on the left side or left lateral decubitus
Inspect the sacrococcygeal and perianal areas. Palpate the
anal canal, rectum, and prostate. If the patient cannot
stand, examine the genitalia before doing the rectal
examination.
Genital and rectal examination in women
Lithotomy position: lying supine with hips flexed, abducted,
and externally rotated and knees flexed
Examine the external genitalia, vagina, and cervix. Obtain a
Pap smear. Palpate the uterus and adnexa, Do a
rectovaginal and rectal examination.
Recording your finding
The history and physical examination form the
database for your subsequent assessment of the
patient and your plan with the patient for
management and next steps.
Your written record organizes the information from
the history and physical examination and should
clearly communicate the patients clinical issues to all
members of the health care team.
You should write the record as soon as possible before
the data fade from your memory.
Vital Sign Measurement