The physical examination (PE) is a systematic process of collecting objective data about a patient’s health status. It is an integral part of the comprehensive health assessment, complementing the subjective data obtained from the health history.

Purpose: To establish a baseline of the patient’s physical status, identify actual or potential health problems, evaluate the effectiveness of nursing/medical interventions, and inform clinical decision-making.

Requires skilled use of sensory perception (sight, hearing, touch, smell) and specific techniques.

Should be performed in a structured, organized manner to ensure completeness and efficiency.

Preparation for the Examination

1. Examiner Preparation:

   • Review relevant patient data (history, previous records, vital signs, lab results).

   • Ensure adequate knowledge of anatomy, physiology, and common pathologies relevant to the patient’s condition.

   • Perform hand hygiene immediately before beginning the examination. Wear gloves as indicated by standard precautions (e.g., potential contact with body fluids, non-intact skin).

2. Equipment Preparation:

   • Gather necessary equipment: Stethoscope (diaphragm and bell), penlight or flashlight, blood pressure cuff, thermometer, pulse oximeter, measuring tape, watch with second hand, visual acuity chart (e.g., Snellen), tongue depressor, cotton swabs, reflex hammer, tuning fork (for vibration/hearing tests), gloves.

   • Ensure equipment is clean, functional, and readily accessible.

3. Environment Preparation:

   • Provide privacy: Close curtains, doors.

   • Ensure adequate lighting: Use natural or artificial light; penlight for focused areas.

   • Maintain a comfortable room temperature to prevent chilling.

   • Minimize noise and interruptions to facilitate auscultation and patient focus.

   • Position examination surfaces appropriately for patient comfort and examiner access.

4. Patient Preparation:

   • Explain the purpose and steps of the examination to the patient.

   • Obtain verbal consent to proceed.

   • Ensure the patient’s comfort and dignity: Offer the opportunity to use the restroom before starting, provide gown/drapes, explain necessary exposure before uncovering areas.

   • Position the patient appropriately for each part of the examination (e.g., sitting, supine, side-lying). Adjust based on patient mobility, pain, or condition.

The Examination Techniques

The four primary techniques used in physical examination are:

1. Inspection:

   • The process of observing the patient systematically.

   • Begins the moment you first encounter the patient (general survey).

   • Requires good lighting and adequate exposure of the body part being examined.

   • Observe for size, shape, color, symmetry, position, texture, movement, and overall appearance. Note any odors.

   • Compare one side of the body to the other for symmetry.

2. Palpation:

   • The use of touch to assess texture, temperature, moisture, organ location and size, swelling, vibration or pulsation, rigidity or spasticity, crepitation, presence of lumps or masses, and presence of tenderness or pain.

   • Different parts of the hand are used for different sensations:

     • Fingertips: Fine tactile discrimination (texture, swelling, pulsation, presence of lumps).

     • Dorsum (back) of hands/fingers: Best for assessing temperature.

     • Ulnar surface/base of fingers: Best for assessing vibration (e.g., fremitus).

     • Palmar surface/finger pads: Best for assessing position, shape, consistency of organs/masses.

   • Techniques:

     • Light palpation (approx. 1 cm deep): Assess texture, moisture, masses, tenderness. Always perform light palpation before deep palpation.

     • Deep palpation (approx. 4-5 cm deep): Assess organs, masses, and deeper structures. Requires experience and can cause discomfort if not done carefully.

   • Palpate tender areas last.

3. Percussion:

   • Tapping the body surface with short, sharp strokes to assess the underlying structures.

   • Produces a palpable vibration and a characteristic sound depending on the density of the underlying tissue.

   • Used to: Map the location and size of organs, signal the density of a structure (air, fluid, solid), detect abnormal masses (if superficial), elicit deep tendon reflexes (using a reflex hammer – a form of direct percussion).

   • Methods:

     • Direct (immediate): Striking the body surface directly (e.g., tapping sinus areas).

     • Indirect (mediate): Using the middle finger of the non-dominant hand (pleximeter) placed firmly on the body surface, and striking its distal interphalangeal joint with the fingertip of the dominant hand (plexor).

   • Characteristic Sounds:

     • Resonance: Clear, low-pitched (e.g., healthy lung tissue).

     • Hyperresonance: Louder, lower-pitched than resonance (e.g., overinflated lungs as in emphysema, pneumothorax – abnormal in adults).

     • Tympany: High-pitched, musical (e.g., over the abdomen filled with air).

     • Dullness: Soft, muffled thud (e.g., over dense organs like the liver or spleen, consolidated lung tissue, effusions).

     • Flatness: Very soft, dead stop of sound (e.g., over bone or muscle, large pleural effusion).

4. Auscultation:

   • Listening to sounds produced by the body, using a stethoscope.

   • Sounds are produced by movements of air or fluid within body systems (e.g., breath sounds, heart sounds, bowel sounds, vascular sounds).

   • Requires a quiet environment.

   • Stethoscope Use:

     • Diaphragm (larger side): For high-pitched sounds (breath, bowel, normal heart sounds). Press firmly against the skin.

     • Bell (smaller side): For low-pitched sounds (extra heart sounds like murmurs, bruits). Hold lightly against the skin.

   • Listen systematically over appropriate areas. Note the characteristics of the sounds (intensity, pitch, duration, quality, frequency).

Systematic Approach to Examination

A systematic approach ensures all body systems are assessed and prevents omissions. Common methods include:

1. Head-to-Toe: Proceeds in a logical geographical sequence, starting from the head and progressing downwards. Often combined with system assessment within each region.

   • General Survey & Vital Signs

   • Head & Face, Eyes, Ears, Nose, Mouth & Oropharynx (HEENT)

   • Neck (including lymph nodes, thyroid, carotid arteries)

   • Skin & Nails (often integrated throughout, but also specific assessment)

   • Thorax & Lungs (Respiratory system)

   • Breasts & Axillae

   • Heart & Peripheral Vascular System (Cardiovascular)

   • Abdomen (Gastrointestinal, Genitourinary assessment often begins here)

   • Upper Extremities (Skin, pulses, range of motion, strength, sensation)

   • Lower Extremities (Skin, pulses, range of motion, strength, sensation, edema)

   • Genitalia & Perineum (Often deferred or performed by/with a chaperone; culturally sensitive)

   • Rectum & Anus (Often deferred unless indicated)

   • Musculoskeletal System (integrated or specific assessment of joints, muscles, posture, gait)

   • Neurological System (integrated or specific assessment of mental status, cranial nerves, motor function, sensory function, reflexes)

2. Body Systems: Focuses on completing the assessment of one system before moving to the next (e.g., complete cardiovascular exam, then respiratory exam). Often used in focused assessments or by experienced practitioners.

Combining both methods is common; performing a Head-to-Toe scan while specifically assessing each body system as its anatomical location is reached.

Key Considerations During the Exam

• Maintain Patient Comfort: Position the patient appropriately, use drapes, minimize exposure, be gentle during palpation.

• Observe Patient Response: Note facial expressions, body language, and verbal cues indicating pain, discomfort, or anxiety.

• Adapt Techniques: Modify the examination based on the patient’s age, physical limitations (e.g., inability to sit up), cognitive status, cultural background, and current medical condition.

• Prioritization: In urgent situations, focus the examination on immediate life threats (e.g., ABCs – Airway, Breathing, Circulation).

• Communicate Findings: Explain findings to the patient in understandable terms.

Documentation

• Record all objective findings accurately, concisely, and in a timely manner.

• Use clear, descriptive, and objective language. Avoid vague terms (e.g., “lungs clear” vs. “Lungs auscultated anteriorly and posteriorly; breath sounds clear to auscultation in all fields; no adventitious sounds noted”).

• Document normal findings (“WNL – Within Normal Limits” or describe specifics if preferred/required by policy) as well as abnormal findings.

• Include measurements where relevant (e.g., lesion size, edema depth, pulse rate/rhythm).

• Utilize appropriate medical terminology and abbreviations according to institutional policy.

• Documentation serves as a legal record and facilitates communication among healthcare providers.