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Putting the Examination Together


The Techniques

The previous chapters dealt with the individual organ systems and the history and physical examinations related to each of them. The purpose of this chapter is to help the student assimilate each of the individual examinations into one complete and smoothly performed examination.

Ideally, a complete examination is performed in an orderly, thorough manner with as few movements as possible required of the patient. Most errors in performing a physical examination result from a lack of organization and thoroughness, not from a lack of knowledge. Evaluate each part of the examination carefully before moving on to the next part. The most common errors in performing the physical examination are related to the following:

  • Technique

  • Omission

  • Detection

  • Interpretation

  • Recording

Errors in technique are related to lack of order and organization during the examination, faulty equipment, and poor bedside etiquette. Errors of omission are common in examinations of the eye and nose; auscultation of the neck vessels, chest, and heart; palpation of the spleen; rectal and genital examinations; and the neurologic examination. Errors of detection are those in which the examiner fails to find abnormalities that are present. The most common errors of this type involve thyroid nodules, tracheal deviation, abnormal breath sounds, diastolic murmurs, hernias, and abnormalities of the extraocular muscles. Errors in interpretation of findings occur most commonly with tracheal deviation, venous pulses, systolic murmurs, fremitus changes, abdominal tenderness, liver size, eye findings, and reflexes. The most common types of recording errors are related to descriptions of heart size and murmurs, improper terminology, and obscure abbreviations.

The following complete examination sequence is the one the author uses commonly and is demonstrated in the video presentation. There is no right or wrong sequence. Develop your own approach. Just be sure that at the end of whichever technique you use, a complete examination has been performed.

In most situations, the hospitalized patient will be lying in bed when you arrive. After introducing yourself and documenting a complete history, you should inform the patient that you are ready to begin the physical examination. Always start by washing your hands or using a hand sanitizer.

The reader is advised now to watch the video presentation to review the complete physical examination of the man and the breast and pelvic examinations of the woman. The video will help you put the examination together.

Patient Lying Supine in Bed

General Appearance

Inspect the patient's facial expression (see Chapter 13 , The Chest; Chapter 14 , The Heart; Chapter 17 , The Abdomen; and Chapter 21 , The Nervous System).

Vital Signs ( Chapter 14 , the Heart)

  • 1

    Palpate blood pressure in right arm.

  • 2

    Auscultate blood pressure in right arm.

  • 3

    Auscultate blood pressure in left arm. 1

    1 If the blood pressure is elevated in the upper extremity, blood pressure in the lower extremity must be assessed to exclude coarctation of the aorta. The patient is asked to lie prone, and blood pressure by auscultation is determined (see Chapter 14 , The Heart).

Have Patient Sit Up in Bed

Vital Signs

Check for orthostatic changes in left arm (see Chapter 14 , The Heart).

Have Patient Turn and Sit With Legs Dangling Off Side of Bed

Vital Signs

  • 1

    Palpate radial pulse for rate and regularity (see Chapter 15 , The Peripheral Vascular System).

  • 2

    Determine respiratory rate and pattern (see Chapter 13 , The Chest).

Head ( Chapter 9 , the Head and Neck)

  • 1

    Inspect cranium.

  • 2

    Inspect scalp.

  • 3

    Palpate cranium.

Face ( Chapter 8 , the Skin, and Chapter 9 , the Head and Neck)

  • 1

    Inspect face.

  • 2

    Inspect skin on face.

Eyes ( Chapter 10 , the Eye)

  • 1

    Assess visual acuity, both eyes.

  • 2

    Check visual fields, both eyes.

  • 3

    Determine eye alignment, both eyes.

  • 4

    Test extraocular muscle function, both eyes.

  • 5

    Check pupillary response to light, both eyes.

  • 6

    Test for convergence.

  • 7

    Inspect external eye structures, both eyes.

  • 8

    Perform ophthalmoscopic examination, both eyes.

Nose ( Chapter 11 , the Ear and Nose)

  • 1

    Inspect nose.

  • 2

    Palpate nasal skeleton.

  • 3

    Palpate sinuses (frontal, maxillary), both sides.

  • 4

    Inspect nasal septum, both sides.

  • 5

    Inspect turbinates, both sides.

Ears ( Chapter 11 , the Ear and Nose)

  • 1

    Inspect external ear structures, both sides.

  • 2

    Palpate external ear structures, both sides.

  • 3

    Evaluate auditory acuity, both sides.

  • 4

    Perform Rinne test, both sides.

  • 5

    Perform Weber test.

  • 6

    Perform otoscopic examination, both sides.

  • 7

    Inspect external canal, both sides.

  • 8

    Inspect tympanic membrane, both sides.

Mouth ( Chapter 12 , the Oral Cavity and Pharynx)

  • 1

    Inspect outer and inner surfaces of lips.

  • 2

    Inspect buccal mucosa.

  • 3

    Inspect gingivae.

  • 4

    Inspect teeth.

  • 5

    Observe Stensen and Wharton ducts, both sides.

  • 6

    Inspect hard palate.

  • 7

    Inspect soft palate.

  • 8

    Inspect tongue.

  • 9

    Test hypoglossal nerve function (see Chapter 21 , The Nervous System).

  • 10

    Palpate tongue.

  • 11

    Inspect floor of mouth.

  • 12

    Palpate floor of mouth.

  • 13

    Inspect tonsils, both sides.

  • 14

    Inspect posterior pharyngeal wall.

  • 15

    Observe uvula as patient says “Ah” (see Chapter 21 , The Nervous System).

  • 16

    Test gag reflex (see Chapter 21 , The Nervous System).

Neck ( Chapter 9 , the Head and Neck)

  • 1

    Inspect neck, both sides.

  • 2

    Palpate neck, both sides.

  • 3

    Palpate lymph nodes of head and neck, both sides.

  • 4

    Palpate thyroid gland by anterior approach.

  • 5

    Evaluate position of trachea (see Chapter 13 , The Chest).

Neck Vessels ( Chapter 14 , the Heart)

Inspect height of jugular venous pulsation, right side.

Neck 2

2 The examiner should now go to the back of the patient while the patient remains seated with legs dangling off the side of the bed.

( Chapter 9 , The Head and Neck)

  • 1

    Palpate thyroid gland by posterior approach.

  • 2

    Palpate for supraclavicular lymph nodes, both sides.

Posterior Chest ( Chapter 13 , the Chest)

  • 1

    Inspect back, both sides.

  • 2

    Palpate back for tenderness, both sides.

  • 3

    Evaluate chest excursion, both sides.

  • 4

    Palpate for tactile fremitus, both sides.

  • 5

    Percuss back, both sides.

  • 6

    Evaluate diaphragmatic excursion, right side.

  • 7

    Auscultate back, both sides.

  • 8

    Palpate for costovertebral angle tenderness, both sides (see Chapter 17 , The Abdomen).

Sacrum ( Chapter 14 , the Heart)

Test for edema.

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