Look, Listen, and Feel: The Parts of the Physical Exam
There are four major elements to any physical exam maneuver:
In general, it’s helpful to think of a physical exam as a test of what you’ve already deduced from the patient through careful questioning. The way you conduct your exam will either confirm things you already suspect from the history or prompt new questions and investigations. Think of examining a patient as progressing in order from less to more invasive, ranging from simple observation to listening with a specialized tool like a stethoscope.
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Inspection involves observation for abnormal findings. A general inspection begins the moment the patient walks into the room. For instance, are they limping or holding a body part in pain? Is their gait abnormal, or are they shuffling their feet when they walk? Is there a visible rash or loss of muscle mass or tissue that implies significant weight loss? Inspection provides vital clues to a patient’s overall health.
Palpation is the process of feeling a body part for abnormalities. While most people think of the abdomen when they think of palpation, this is not the only way you can use your hands to examine a patient. Abnormal or sustained beats felt in the area above the heart, the contour of peripheral pulses, the temperature of the skin, or whether a lesion is raised or flat are all examples of how palpation helps to narrow down a differential diagnosis.
Percussion utilizes the resonant properties of different tissues to determine things such as the presence or absence of fluids, solids, or air in a body cavity. This is done by striking a hollow body surface with a finger, either directly, or by putting one hand on the surface and striking that finger with a finger of your other hand. Mixtures of solids, fluids, and air conduct sound at different frequencies. This produces different tones you can distinguish with a trained ear. Percussion is one of the more difficult physical exam skills for the early learner to master. Even for experienced practitioners, it usually can only suggest rather than confirm a diagnosis.
Auscultation uses a stethoscope to listen for the movements and sounds made by internal organs – most commonly the heart, lungs, and abdomen. Normal sounds can be initially quite difficult to distinguish from abnormal sounds, so try to listen to as many normal sounds as you can to start. With experience, you’ll discover when something deviates from the usual pattern! Auscultation is among the most difficult skills for novice learners to master because of the breadth of sounds.
Figure out your own best practices
Keep in mind that you don’t need to use every single technique you learn on every single patient. Most doctors will eventually develop a “core” general screening exam they use on most patients. A thorough history guides the need for more specific maneuvers that can help to answer questions about whether a disease or condition is more or less likely. Becoming comfortable with all the parts of the physical exam is essential for detecting abnormal findings. It also instills confidence in your patient that you know what you are doing.
The key to building expertise in the physical exam is to practice, practice, practice.
Practice on anyone you can – roommates, friends, family, even a pillow, or yourself!
Using checklists of each part of the exam and performing them in the same order helps translate the process into muscle memory. By using these techniques, your skills will progress fast! When the exam becomes second nature, you’ll be surprised at just how fast you’re able to distinguish normal from abnormal.