Physical examination must be thorough and efficient without being overdone and exhausting to the patient. Whichever system or anatomical region is examined, the process relies on four skills, i.e. inspection, palpation, percussion and auscultation, and is designed to elicit the appropriate clinical signs. Whereas examination of the various systems is crucial to the management of patients with medical disorders, in surgical practice physical examination is more commonly focused on anatomical regions (head and neck, ear, nose, throat, breasts, abdomen and limbs), although assessment of the respiratory, cardiovascular and renal systems is often also necessary. Certain vital signs – temperature, blood pressure, pulse rate, pulse volume and respiratory rate are performed routinely in all but minor cases.
Inspection requires a trained eye actively to detect abnormalities. Inspection consists of a detailed and systematic scrutiny of the anatomical region and entails close observation of abnormal movements of the parietes and body contour, as well as surface abnormalities (scars, surface lesions, lumps, bulges) and complexion of the skin, lips, conjunctival membranes and sclera. Good lighting is essential, particularly for the detection of abnormal discoloration (pallor, cyanosis, jaundice).
Palpation relies on the tactile sense organs in the fingers to outline surface irregularities, tension of the abdominal walls, lumps and enlarged organs. The exercise should be carried out by a relaxed warm hand and should be conducted gently and in an orderly fashion. In general, the more you press, the less you feel, and worse still, the patient is hurt.
Percussion is very useful for establishing the consistency of a swelling or organ. Thus a solid lump or organ is dull to percussion. A fluid-containing cyst or body cavity (peritoneal, thoracic) is stony dull to percussion. For the same reason a distended urinary bladder is detected as a localized dull swelling in the suprapubic region. By contrast, air-containing organs (normal ventilated lung, air-containing hollow abdominal viscera) are resonant on percussion (much like a drum). When using percussion to oudine the size or margins of an organ, one should percuss from the resonant to the dull area. The point where the note changes marks the margin of the organ.
Auscultation with the stethoscope requires considerable experience to recognize the normal from the abnormal, and is used to examine the lungs (normal and adventitial breath sounds), heart sounds and murmurs, abdominal bowel sounds, and bruits over stenotic or dilated segments (aneurysms) of arteries.