A century ago, the physical exam was by the gold standard for most diagnoses, but even today the exam is still critical to good patient care. A careful exam guides the appropriate and judicious use of modern tests, technology, and treatments.  It connects us to our patients, makes us better diagnosticians, and contributes to the trust so essential to the physician-patient relationship.

A thorough and thoughtful physical exam is a portable, affordable, accessible tool that minimizes harm while improving physician and patient confidence and stewardship of healthcare resources.  It is a crucial skill that allows us to evaluate and prioritize diagnostic hypotheses, helping to guide and monitor treatments and further testing. And with proper consent, the power of touch can helps us connect to and heal our patients.

As your colleagues and teachers, we believe that the physical exam:

• Creates opportunities for us to foster meaningful connection, build trust and humanize our care
• Is a valuable mindful practice that encourages healing and equity
• Connects the anatomy and pathophysiology to the human in front of us
• Increases our confidence in the differential diagnosis and fosters our communication with patients

In Immersion, you will begin to master the thorough, head-to-toe exam that might be performed on a new patient.  You will revisit the exam alongside the physiology and pathophysiology of each organ system during the Foundations phase. We believe that developing excellent physical exam skills will serve you and your patients well throughout your career and we are committed to building, maintaining, and using these skills for ourselves.

To maintain the rapport and relationship that you built during the interview, stay sensitive to your patient’s comfort as you perform the exam. Our hands may feel cold, some elements of the exam may be uncomfortable or confusing, and the power differential between clinician and patient may discourage people from speaking up. Carefully observe for any signs of discomfort or anxiety and check in frequently with your patient, adjusting your approach as needed.

Learning the values of observation, equity, access, mindfulness and trust through the physical exam.

Privacy and modesty

To maximize privacy, ask if your patient would like others to leave the room during the exam. Closing the privacy curtain around the patient and close the door to the room. For a comprehensive exam, a patient would typically be dressed in a gown. For a more limited exam in the clinic, the exam may be performed around clothing. In either case, it is important to fully expose the area being examined while maintaining your patient’s modesty.

Double draping

Double draping refers to the adjustment of your patient’s gown and a sheet to maintain modesty and maximize comfort throughout the physical exam. Please practice this skill during each of your Immersion PE labs so you will be prepared when you see your first hospital patient.

For a complete exam, your patient will be dressed in a gown that is typically tied in the back and may have snaps at the shoulders. A sheet is draped over the lap. These are moved during the exam so that only the part of the body being examined is exposed – either ask your patient to move them or ask permission before moving them yourself. Most patient gowns also have snaps at the shoulders that allow exposure of the upper chest while keeping the breasts covered.

The ideal position of the gown and drape is different for each section of the exam. If you’re not sure how to position the gown and drape in your physical exam labs, ask us for suggestions for how to maintain modesty and comfort.

Core techniques

The physical exam is built on four core techniques: inspection, palpation, percussion, and auscultation. These techniques are typically performed in the same sequence for each body region, starting with inspection.

Inspection

Definition: The use of intentional observation to notice findings of illness and disease.

Inspection is the least mechanical and the hardest to learn of the physical exam techniques. It requires slowing down, which can be hard for all of us – in this digital age, the human attention span has been shortened by more than half.

Practice taking a conscious pause to observe and truly notice your patient’s appearance, affect, and surroundings and notice any findings of distress or disease, like facial expression, nonverbals, scars from previous surgeries, IV ports or skin changes. As you observe, correlate what you see with what you’ve learned from your patient’s history. If anything is unexplained, ask! For example, “I notice you have this scar. May I ask what it is from?”

Observing general appearance

You’ll already have carefully observed your patient as you interviewed them. Take a conscious moment to pause and consider what you have seen. For example,

• At first glance, do they look well or ill? This first impression of “sick” can help to establish the urgency of the situation.
• Are there nonverbal cues suggesting anxiety, discomfort, or pain?
• What is the level of consciousness? Is your patient alert, or are they sleepy or confused?
• How do they use speech and language? Are there any unusual features that suggest a neurologic or mental health disorder?
• Are there signs of poor nutrition, such as wasting around the temples or loose clothing or jewelry?
• Are there signs of poor perfusion, such as confusion or in lighter skinned individuals, pallor of the skin?
• Are there bruises or injuries that might suggest child abuse or intimate partner violence?

Palpation

Definition: The use of touch to characterize an area of the body

This technique is used to evaluate pulses, to assess different organs, and to observe for tenderness, masses, or swelling. You will use different parts of your hands and different techniques to palpate different parts of the body. For your patient’s comfort, make sure your hands are warm before palpation and begin away from any tender areas.

Percussion

Definition: Striking a part of the body to observe the sound and feeling produced.

Percussion can be either direct (your hand strikes your patient’s body) or indirect (your hand strikes your own fingers, which are pressed against their body). To practice, indirect percussion, place the third finger of your left hand firmly against a table or half filled plastic jug. Tap on your middle or distal phalanx using the tip of your right third finger as a mallet, swinging your right hand at the wrist. You are listening for the sound AND feeling the quality of the vibrations in the finger pressed against the body. Vary the pressure you apply with the finger pressed against the jug or table – do you notice the difference in percussion quality?

Auscultation

Definition: The use of a stethoscope to hear sounds produced by internal organs.

A quiet environment will increase the accuracy of your exam. Ask your patient and visitors tobe quiet, close the door, and mute the TV. With patients, always auscultate on bare skin, even if you are doing a brief exam in clinic and must work around clothing. Clothing can create sounds that fool you into thinking your patient has an abnormal finding or can make it harder to pick up on subtle abnormalities. You may not always see this modeled in clinical practice, where the environment and fast pace sometimes get in the way, but this is what you should strive for.

Examine and try out your stethoscope before lab. The stethoscope gifted by the Alumni Association is a tunable stethoscope with a larger diaphragm for adults and a smaller one for children. Apply firm pressure with either side to hear high frequency sounds, and light pressure for lower pitched sounds.

“Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.”- Sir William Osler

Classic stethoscopes have a concave bell on one side that is used detect lower pitched sounds. Your stethoscope includes a rubber rim that converts the pediatric side of your stethoscope to a bell. Since you may see kids in clinic, we recommend using your stethoscope as is.

After placing your stethoscope in your ears with the earpieces pointing forward, tap against the surface you plan to apply to your patient’s skin. You should hear a fairly loud ‘tap’ through the earpieces. If you don’t, twist the head of the stethoscope with one hand while holding the end of the tubing with the other. After the head turns, tap again to confirm that the correct side of the head is transmitting sound through the earpieces. Place your stethoscope in each of the following locations on yourself and see if you hear something like the sounds below! Use headphones for these and other audio clips in this guide.

Heart sounds: listen just to the right of the sternum.

Bowel sounds: listen over the middle of the abdomen

Lung sounds: listen on the side of the chest, over the lower ribcage

Trauma-informed approach

Over half of people have experienced some type of trauma, such as emotional, physical or sexual abuse or violence in their home or community. The long term effects vary person to person but a growing body of research shows that trauma has long-lasting health impacts that increase the need for health care. Trauma can also impact one’s feeling of safety in the clinical setting and failure to recognize this can lead well-meaning health care providers to inadvertently re-traumatize their patients. The physical exam can be particularly stressful, and fear and anxiety about the exam can lead some patients to avoid healthcare altogether.

Trauma-informed care emphasizes physical, psychological and emotional safety, to help survivors of trauma rebuild a sense of control and empowerment. Using a trauma-informed approach to the physical exam with all patients can maximize comfort and trust for all patients. The goal is for patients to be informed and in control throughout the exam.

Some exam elements, like the oral exam, thyroid exam and genital exam may feel especially threatening to those who have experienced trauma. Always explain what you will do and why and ask the patient’s permission before starting. Because of the power differential inherent to the physician patient relationship, some patients may feel uncomfortable speaking up. In your hospital tutorials, where we are not part of the care team, you can explicitly tell patients that it is okay to decline any aspect of the exam that they are uncomfortable with.

Reporting the Exam

The exam is reported in a standard and predictable way, so your reader or listener can anticipate and interpret your findings. To maximize efficiency and patient comfort, a complete exam is usually PERFORMED from head-to-toe. However, it is REPORTED by organ system.

For example, the carotid pulses are checked as the neck is examined and the foot pulses are checked at the end of the exam, but these are both reported with the cardiovascular exam.

In Immersion, you will learn to report typical physical exam findings. During your blocks, you will learn much more about pathophysiology and abnormal findings. We will return to reporting the exam in each advanced physical exam workshop.

Standard vocabulary and reference points

The reference points and terms you have learned in Anatomy are also used to describe physical exam findings.  These are based on the anatomic position: standing and facing forward, with the palms facing forward. Here’s a refresher.

Typical findings

As you learn the exam in Immersion, you should also learn how to describe the usual findings in a healthy person. The sample document below is for a healthy person with no unusual or abnormal findings.

Sample Documentation

Abnormal findings

Describe abnormal findings as clearly and concisely as you can. You’ll learn more about abnormal exam findings, how to describe them, and what they mean as you complete each block. This list of common abnormalities can serve as a reference in the mean time (you don’t need to read the whole thing now).

Problem focused exam

Knowledge Check